Transitional Care Management
Follow-up and a visit after a stay in a hospital, rehab or skilled nursing facility.
The gap after discharge
The transition home is where continuity matters most.
Moving between a hospital, a rehab, a nursing home and home is a risky time. Instructions get lost. Medications change. Follow-up visits are missed. BridgeHealth Solutions closes that gap. We stay with the patient after the transition and keep the care plan moving.
How we help
A steadier path forward for every patient.
01Coordinate care
02Manage medications
03Monitor health remotely
04Prevent readmissions
05Support patients at home
06Educate patients and families
07Improve health outcomes
Care management
Support that follows the patient.
Chronic Care Management
Monthly care coordination for patients with two or more long-term conditions.
Principal Care Management
Monthly care coordination focused on one serious condition.
Annual Wellness Visits
A yearly visit with a personal prevention plan.
Remote Patient Monitoring
Devices send blood pressure, weight, glucose and oxygen readings so changes are caught early.
How it works
Simple for your team. Reassuring for the patient.
01
You refer
Send us a patient who needs support.
02
We enroll with consent
The patient or family agrees to the program.
03
We coordinate care
We review medications, set up follow-up and monitor health.
04
We report back
Your team stays informed at every step.
A partner, not another hurdle
No cost to your facility.
Our services are billed to the patient's insurance, such as Medicare Part B.
Who we partner with
Built around the way care teams already work.
Hospitals and case managers
Nursing homes
Rehabilitation centers
Assisted living communities
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About the founder
Care coordination starts with listening.
Dirksen J. Taguiam, DNP, RN, APN
Founder & CEO, Nurse Practitioner
I started BridgeHealth Solutions to make sure patients don’t get lost after discharge. With a focus on communication and coordination, we help patients, families and care teams stay connected for better health outcomes.
Newsletter
Stay in touch.
Short updates for hospital and facility teams on keeping patients connected after discharge. Unsubscribe at any time.
Contact
We can visit your facility and meet your team.
+1 (908) 842-4828 contact@BridgeHealth.Solutions
www.BridgeHealth.Solutions
Serving Ocean County, New Jersey