For Case Managers & Discharge Planners
Help patients leave with a clearer path to follow-up.
Alderon Medical is preparing a telehealth-first pathway for eligible adults who need transitional follow-up and an ongoing primary-care relationship after discharge.
We are building the model around a problem discharge teams see every day: a patient is medically ready to leave, but outpatient continuity is uncertain, fragmented, delayed, or absent.
The Transition Gap
Discharge is not the end of the care plan.
The days after discharge often determine whether the plan made inside the hospital becomes a workable plan at home.
No established primary-care clinician
Some patients leave with follow-up instructions but no practical outpatient clinician available to assume longitudinal responsibility.
Multiple changes occur at once
New medications, discontinued medications, pending tests, specialty referrals, new diagnoses, and changing care instructions can be difficult to reconcile outside the hospital.
One episode becomes another disconnected episode
Without longitudinal follow-up, patients can move from hospital to urgent care, emergency care, or another fragmented encounter without an ongoing primary-care plan.
Referral Fit
Who may be appropriate for Alderon follow-up?
Clinical appropriateness, state availability, telehealth suitability, and Alderon’s current scope of services must be considered for each prospective patient.
Adults without reliable primary-care access
Patients who need an ongoing primary-care relationship and may benefit from a telehealth-first model.
Patients with a defined post-discharge plan
Individuals whose discharge plan includes outpatient follow-up that falls within Alderon’s available primary and transitional-care scope.
Patients appropriate for telehealth
Patients whose needs can reasonably and safely be addressed through telehealth, with escalation to in-person or higher-acuity care when necessary.
Patients managing multiple changes
Individuals who may benefit from review of medication changes, follow-up needs, referrals, and the overall outpatient care plan.
Patients transitioning from post-acute care
Appropriate patients leaving rehabilitation, skilled nursing, or another post-acute setting who need ongoing outpatient continuity.
Patients seeking a longitudinal relationship
Alderon’s goal is not simply another isolated encounter. When appropriate, transitional care can lead into an ongoing primary-care relationship.
Referral Workflow
A simple professional pathway.
The final production referral workflow will be implemented through secure systems appropriate for patient information. The public Alderon website is not used to transmit PHI.
Identify
The discharge or care-management team identifies a patient who may need transitional follow-up or an ongoing primary-care relationship.
Determine fit
Confirm that Alderon serves the patient’s state and that the intended follow-up appears appropriate for Alderon’s telehealth-first scope.
Secure handoff
Patient-specific information is transmitted only through the secure referral or patient-intake pathway designated by Alderon.
Follow-up
Appropriate patients enter Alderon’s transitional or primary-care workflow, with escalation or external referral when needs fall outside scope.
Transitional Follow-Up
Organize the plan the patient is taking home.
Transitional follow-up is an opportunity to review what changed during hospitalization or post-acute care and translate those changes into a workable outpatient plan.
Once services launch, the exact follow-up available will depend on the patient’s clinical needs, Alderon’s scope, state availability, and the information available at the time of care.
Follow-up may include:
- Review of discharge instructions
- Medication reconciliation
- Review of medication additions, discontinuations, and dose changes
- Review of pending tests or recommended follow-up
- Coordination of indicated referrals
- Assessment of ongoing primary-care needs
- Review of warning signs and appropriate escalation
- Development of a longitudinal care plan when appropriate
Built for Care Coordination
A resource for the professionals arranging the next step.
Case Management
A possible outpatient pathway for appropriate patients whose longitudinal follow-up is uncertain.
Discharge Planning
A telehealth-first option to consider when creating a realistic post-discharge follow-up plan.
Social Work
An additional care-access resource for eligible adults facing geographic or logistical barriers.
Care Coordination
A model designed to support continuity between transitional needs and ongoing primary care.
Utilization Management
A defined outpatient option when appropriate care can safely continue outside higher-acuity settings.
Population Health
A potential access pathway for populations with primary-care gaps or limited local availability.
Hospital Medicine
A possible follow-up resource when a medically appropriate patient lacks established outpatient continuity.
Post-Acute Teams
A longitudinal primary-care pathway for selected patients leaving rehabilitation or facility-based care.
Clinical Boundaries
The right referral starts with the right scope.
Alderon is being developed as a telehealth-first outpatient primary-care practice. Once clinical services launch, it will not be a substitute for emergency, inpatient, or other higher-acuity care.
Appropriate to consider
- Transitional outpatient follow-up
- Longitudinal primary-care access
- Medication reconciliation
- Review of outpatient follow-up needs
- Coordination of routine referrals
- Stable chronic-condition follow-up within scope
Requires another pathway
- Medical emergencies
- Unstable or rapidly worsening conditions
- Care requiring immediate hands-on evaluation
- Inpatient-level monitoring or treatment
- Services outside Alderon’s current clinical scope
- Care in a state where Alderon is not authorized to practice
Alderon’s public WordPress website is informational and is not used to collect protected health information. Patient-specific clinical information, records, diagnoses, medications, discharge summaries, and other sensitive information should be transmitted only through a secure workflow specifically designated by Alderon.
Related Professional Pathways
More ways to work with Alderon.
Professional Inquiries
Building a discharge pathway?
If your organization is exploring future options for transitional follow-up or ongoing primary-care access, Alderon can discuss the intended referral population, planned geographic availability, clinical scope, source attribution, and secure handoff workflow before launch.
Talk with Alderon.
Use the Professional Interest pathway for referral, discharge, and organizational inquiries.