For patients leaving a skilled nursing facility, discharge is not the finish line. It is often the most critical transition in their care journey. Yet, the current discharge process is often chaotic. New prescriptions collide with old home routines, creating a web of confusion that can lead to adverse events.
Clarest Health’s Transitions of Care Program represents a structurally different approach. We deliver a clinically supervised program designed to provide care, not confusion, solving the problem at its source before the patient ever walks out the door.
Proactive Care during Transitions
We built a better, safer path that replaces post-discharge chaos with proactive care.
- Pre-Discharge Activation: We stop confusion before it starts. A pharmacy liaison reviews the in-facility medication record and initiates reconciliation before the patient leaves the building, structurally closing the gap where the most dangerous errors occur.
- Dedicated Care Liaisons: Supervised by pharmacists, they manage the entire transition, from bridging supply to scheduling follow-ups, ensuring nothing falls through the cracks.
- All-Prescriber Outreach: A patient’s health story involves multiple doctors, which often leads to conflicting instructions. A care liaison identifies and reaches out to the patient’s prescribers, cutting through the confusion to ensure a safe, unified plan.
- In-Home Supply Assessment: Before e-prescribing a single new medication, we assess what the patient already has at home. This critical step provides clarity, prevents dangerous double-dosing, and protects our partners from duplicate billing exposures.
- PCP-Calibrated Fills: We know the discharge medication list is a starting point, not a final regimen. We calibrate the duration of the first fill based on the patient’s first follow-up PCP appointment, preventing wasted medication and patient confusion when adjustments are inevitably made.
- Transparent Outcomes Reporting: We track patient-level outcomes, including Proportion of Days Covered (PDC), 30-day and 90-day readmission rates, and ED visits. We report these outcomes back to you as the clear evidence base for our partnership.
For Skilled Nursing & Post-Acute Facilities
We start before your patient leaves. Every other program starts after they’re already home.
Under CMS rules, facilities are financially and reputationally accountable for patient outcomes for 30 days post-discharge. With 73% of skilled nursing facilities receiving CMS penalties for excess readmissions, you need a partner you can trust.
Clarest extends your clinical reach into the home without requiring you to hire, train, or manage the staff to do it. We provide visible, documented evidence of post-discharge care that you can confidently share with payer partners and quality reviewers.
For Health Plans & Value-Based Care
Clarest closes the post-discharge medication gap at the source before it becomes a readmission.
For health plans, readmissions are a direct cost liability and a major Star Rating risk. Because medication non-adherence and regimen confusion are the leading modifiable contributors to preventable readmissions, you need more than a pharmacy delivery service.
When you partner with Clarest, you are investing in a documented outcomes improvement program. We deliver measurable reductions in 30-day and 90-day readmissions, improved PDC scores, and reduced ED utilization, providing the patient-level outcome data you need to report to CMS and secure your Star Ratings.
Ready to Transform Your Care Transitions?
Let’s collaborate to build a transition strategy defined by proactive care, not post-discharge confusion.