hospitals health systems

Health Systems & ACOs


Evolution Health is a care coordination and transitional care management solution that helps reduce gaps in care, enhance patient experience and improve overall financial performance. Our model provides a framework to simplify the discharge process and increase emergency department visit capability leading to:

  • Reduced preventable readmissions
  • Reduced avoidable or unnecessary Emergency Department visits
  • Decreased length of stay for appropriate patient populations
  • Streamlined patient throughput
  • Enhanced HCAHPS scores
  • Improved integration with primary care and other healthcare providers
  • Open hospital beds for new patients
  • Fee for service/fee for value flexibility

When it's time for patients to leave the hospital, Evolution Health's mobile integrated healthcare practice coordinates with primary care providers, hospitalists and specialists to bridge the gap from hospital to home, hospital to skilled nursing facility, skilled nursing facility to home and/or hospital emergency department to home.

  • Focus on evidence-based interventions delivered by interprofessional care team (mobile pharmacists, social workers, nurses, paramedics and community health workers)
  • 24/7 support with rapid response capability to reduce preventable readmissions and preventable emergency department utilization
  • Patient follow up for 30, 60 or 90 days depending on needs; patient transition back to primary care provider or specialist
    • Hospital to Home
    • Hospital to Skilled Nursing Facility (SNF)
    • SNF to Home    
    • Emergency Department (ED) to Home

Coordinate Care for Better Outcomes

Our team of Transitional Care Coordinators bridge the gap between care settings while working in collaboration with physicians and their care teams to help ensure patients recover and avoid unnecessary trips back to the hospital.

  • Improves coordination and integration of care
  • Improves the overall quality of care
  • Ensures patients complete necessary follow-up
  • Minimizes 911 calls and trips to the ER
  • Reduces length of stay
  • Stops avoidable re-admissions before they happen
  • Lowers costs
  • Uses claims and clinical data to analyze quality and performance to improve outcomes
  • Increases patient satisfaction

Watch how Evolution Health is changing the Mobile Integrated Healthcare landscape.