Helping Patients Move Forward With Confidence
Moving from a hospital or skilled nursing facility back home can be a vulnerable time. Patients and families may be managing new medications, follow-up appointments, wound care instructions, mobility changes, and newly diagnosed conditions—all at once.
Altix Medical helps make these transitions feel more organized and supported. Our team brings care directly to the patient, coordinates with the people involved, and helps keep important needs from getting lost between care settings.
BRIDGING THE GAPS BETWEEN CARE SETTINGS
Because Care Shouldn’t End at Discharge
A discharge plan may involve several providers, medications, tests, and services. Without clear coordination, patients and caregivers can feel overwhelmed and uncertain about what comes next.
Altix Medical works alongside hospitals, rehabilitation centers, skilled nursing facilities, home health agencies, specialists, families, and caregivers to support a smoother transition.
Our goal is to help every member of the care team understand the plan and keep the patient connected to appropriate follow-up care.
OUR TRANSITIONAL CARE SERVICES
Support Tailored to Each Patient’s Needs
Services may include:
• Post-hospital and post-facility follow-up
• Review and reinforcement of discharge instructions
• Medication reconciliation and management
• Assessment of changes in the patient’s condition
• Mobile primary care visits
• Wound and ostomy care
• Remote patient monitoring for eligible patients
• Laboratory and diagnostic coordination
• Imaging and specialty referrals
• Medical equipment coordination
• Nutritional and mobility support
• Patient and caregiver education
• Communication with facility teams and other providers
• Ongoing care-plan updates
Services are based on the patient’s clinical needs, location, available coverage, and applicable provider scope of practice.
A MORE CONNECTED CARE EXPERIENCE
Bringing the Pieces Together
Patients with complex needs are often cared for by several organizations and healthcare professionals. Altix Medical helps connect those pieces through clear communication and practical follow-through.
We may coordinate with:
• Primary care providers
• Specialists
• Hospitals and discharge planners
• Skilled nursing and rehabilitation facilities
• Assisted living communities
• Home health agencies
• Pharmacies
• Laboratories and imaging providers
• Medical equipment suppliers
• Patients, families, and caregivers
With the patient’s authorization, we help share relevant information and recommendations so everyone can work from a more unified care plan.
POST-DISCHARGE SUPPORT
Helping Patients Settle Safely Back Home
The first days and weeks after discharge are an important part of recovery. Our providers can visit the patient where they live to review current needs, clarify the care plan, and identify concerns that may require additional attention.
Support may include:
• Reviewing discharge instructions
• Comparing previous and current medications
• Evaluating new or worsening symptoms
• Checking wounds, ostomies, or other clinical concerns
• Confirming that necessary supplies and equipment are available
• Coordinating laboratory testing and follow-up appointments
• Helping patients and caregivers understand the next steps
This added support can reduce confusion and help patients feel less alone during the transition.
COORDINATED WOUND AND OSTOMY CARE
Maintaining Continuity Beyond the Facility
Wound and ostomy care can become disrupted when a patient moves between care settings. Products may change, instructions may be unclear, or follow-up may be delayed.
Altix Medical helps maintain continuity by:
• Reviewing the existing treatment plan
• Reassessing the wound or ostomy after discharge
• Providing clear, updated care instructions
• Coordinating dressings, supplies, and medical equipment
• Communicating with home health and caregivers
• Arranging diagnostics or specialty referrals when appropriate
• Monitoring progress and adjusting the plan as needs change
Our providers care for the whole patient while addressing the medical factors that may affect healing and recovery.
REMOTE PATIENT MONITORING
An Added Layer of Support Between Visits
When clinically appropriate, eligible patients may benefit from Remote Patient Monitoring after discharge.
Connected devices can securely share health readings such as blood pressure, blood glucose, weight, heart rate, or blood oxygen with the care team. This helps providers follow relevant trends and gives patients additional support between scheduled visits.
SUPPORT FOR PATIENTS AND CAREGIVERS
Clear Guidance When It Matters Most
Caregivers often become responsible for medications, appointments, wound care, mobility support, and monitoring symptoms with little time to prepare.
We help patients and caregivers better understand:
• The discharge and follow-up plan
• Medication changes
• Symptoms that should be reported
• Wound or ostomy care instructions
• How to use prescribed equipment
• Upcoming tests and appointments
• Who to contact with questions or concerns
Our team communicates in clear, approachable language so families feel more informed and confident.
PARTNERSHIPS THAT SUPPORT CONTINUITY
Extending Care Beyond Your Doors
Altix Medical partners with hospitals, skilled nursing facilities, rehabilitation centers, assisted living communities, home health agencies, accountable care organizations, medical practices, and community organizations.
Our transitional and coordinated care services can help partners:
• Extend support beyond discharge
• Improve communication across care settings
• Connect patients with mobile follow-up care
• Address changes in condition more promptly
• Coordinate medications, diagnostics, and referrals
• Support patients with chronic wounds or complex conditions
• Keep families and caregivers better informed
• Strengthen continuity for high-risk populations
We tailor our services to complement your existing discharge process and care-management workflow.
HOW THE PROCESS WORKS
Referral Before or After Discharge
A facility, healthcare professional, patient, or family member contacts Altix Medical.
Information and Coverage Review
Our team gathers the necessary clinical information, discharge records, and insurance details.
Initial Follow-Up
A qualified provider evaluates the patient, reviews the discharge plan, and identifies immediate care needs.
Coordinated Care Plan
We organize appropriate services, which may include primary care, wound care, medication management, diagnostics, monitoring, equipment, or referrals.
Communication
With the patient’s authorization, we share relevant updates with caregivers and other members of the healthcare team.
Continued Support
We follow the patient’s progress and update the care plan as needs change.
CARE THAT CONTINUES BEYOND DISCHARGE
A successful transition is more than arriving home. It means understanding the plan, accessing the right services, and knowing that support is still available.
Altix Medical helps patients, families, and healthcare partners create a more connected path forward—from one care setting to the next.