Why Partner With Us?
Better Outcomes through Collaboration.
We believe great care starts with great partnerships. Our flexible models connect hospitals, rehabilitation centers, and primary care teams to deliver the best possible post-discharge support.
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Our TCM program provides early post-discharge contact and follow-up visits to identify issues before they become complications. By addressing medication concerns, symptom changes, and care coordination needs within days of discharge, we help prevent unnecessary hospital returns and support CMS quality benchmarks.
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We work closely with hospitals, primary care teams, and community providers to ensure every patient receives coordinated, high-quality follow-up care. Through shared communication and seamless transitions, we help improve recovery, patient satisfaction, and overall outcomes.
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Our coordinated, compassionate approach helps patients feel supported every step of the way. Through timely follow-ups, clear communication, and personalized care plans, we ensure every patient feels heard, respected, and confident in their recovery—leading to consistently higher satisfaction and better outcomes.
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Our TCM program bridges the gap between hospitals, primary care, and community providers. We share timely updates, verify discharge plans, and ensure patients fully understand their recovery steps. Through proactive communication, we close information gaps that often lead to confusion, medication errors, or preventable readmissions.
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TCM fosters better communication and collaboration between hospitals, skilled nursing facilities, and outpatient providers—creating a seamless care experience that supports smoother transitions, fewer readmissions, and improved outcomes for patients.
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Our TCM processes follow CMS and HIPAA standards, meeting all Medicare, Nevada Medicaid, and MCO requirements. Every contact, visit, and documentation step is designed for full regulatory compliance.
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Our care doesn’t stop after the first visit. Valley Health ensures every step of the post-discharge process is completed—follow-up calls, medication reconciliation, specialist referrals, and documentation—so nothing falls through the cracks. This consistent communication between patients and providers promotes safety, accountability, and better long-term outcomes.
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Our team bridges the gap after discharge, then transitions patients back to their home care network. This ensures continuity within your provider network, strengthens patient retention, and supports long-term engagement with their new and established providers.
Referral Process
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Providers or case managers send the patient’s basic information, discharge date, and contact details to Valley Health. Supporting documents such as discharge summaries or medication lists may also be included. Submit a referral securely through phone, fax, or email (form below). Contact us to learn more.
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Our care team reaches out to the patient within 2 business days of discharge to review their needs, confirm medications, and provide guidance for next steps.
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The patient completes a face-to-face visit within 7–14 days after discharge, depending on the complexity of care. Our care team ensures a smooth transition, helping to reduce complications and prevent readmissions.
Referral Form
Our Commitments to Providers and Partners:
At Valley Health, we value collaboration and transparency. Our team is dedicated to supporting healthcare partners with efficient communication, compliance, and quality outcomes.
Compliance: We adhere to Medicare, Nevada Medicaid, and Managed Care Organization (MCO) standards in all aspects of care.
Communication: Providers receive timely progress notes and care coordination updates to ensure seamless transitions and continuity of care.
Quality Outcomes: Our Transitional Care Management (TCM) program helps reduce 30-day readmissions and improve patient satisfaction scores, supporting better results for both patients and healthcare systems.
