Facility & Community Care
Primary care that can help connect patients across settings.
Alderon Medical is developing facility primary care and community-care partnership pathways for skilled nursing, long-term care, rehabilitation, assisted-living, post-acute, hospital, and community organizations that need a dependable way to reconnect appropriate adults with longitudinal outpatient care.
The model can support longitudinal primary care, medication reconciliation, chronic-condition management, transitional follow-up, care coordination, and appropriate telehealth access while connecting patients back to local services when hands-on care is required.
- SNF, LTC & post-acute transitions
- Telehealth-first
- Longitudinal primary care
Continuity Across Settings
Facility primary care can help close the gap after a transition.
A patient may leave a hospital, skilled nursing facility, rehabilitation setting, long-term care environment, or other healthcare setting with new medications, new diagnoses, pending testing, specialist recommendations, and an evolving recovery plan.
Facility primary care can provide a consistent outpatient clinical relationship to help organize those next steps and reconnect the patient with longitudinal care.
Care coordination matters: The Centers for Medicare & Medicaid Services identifies coordination after emergency visits, hospital discharge, skilled nursing facility discharge, and other healthcare-facility transitions as part of advanced primary-care management.
Clarify the discharge plan
Review what changed during the recent episode of care, including diagnoses, medications, testing, recommendations, precautions, and expected follow-up.
Reconcile medications
Compare medications before and after a transition to identify duplications, omissions, discontinued therapies, monitoring needs, and questions that need clarification.
Restore longitudinal care
Acute and post-acute needs can be brought back into a broader primary-care plan that also addresses chronic disease, prevention, medications, and future risk.
Coordinate the next setting
Primary care can help connect patients with laboratories, imaging, specialists, rehabilitation, community resources, or in-person evaluation when clinically appropriate.
Potential Partnerships
Partnership pathways for organizations coordinating complex transitions.
Alderon can evaluate partnership opportunities with organizations that need a reliable pathway for appropriate adults to establish or re-establish longitudinal primary care after facility-based, post-acute, or other coordinated care transitions.
Skilled Nursing & Rehabilitation
Support continuity when appropriate adults transition from skilled nursing, inpatient rehabilitation, or other post-acute treatment back into the community.
Long-Term Care & Assisted Living
Explore telehealth-first primary-care pathways for appropriate residents or individuals who need longitudinal outpatient care coordinated with local facility and community resources.
Hospitals & Health Systems
A potential outpatient pathway for appropriate patients who are being discharged without an established primary-care relationship or who need timely transitional follow-up.
Case Management & Discharge Teams
A professional referral pathway for case managers, discharge planners, social workers, utilization management, and care-coordination teams seeking an outpatient continuity option for appropriate adults.
Community & Care-Management Organizations
Collaboration opportunities may include organizations helping adults navigate healthcare access, chronic conditions, transitions of care, and local support services.
LTACH & Complex-Care Partners
Alderon may evaluate follow-up pathways for appropriate adults leaving long-term acute or complex-care settings when outpatient telehealth-first primary care fits the patient’s needs and Alderon’s scope.
The Alderon Model
Facility primary care continues after the handoff.
Alderon’s role is not to replace inpatient physicians, facility medical teams, emergency departments, nursing services, rehabilitation clinicians, or specialists. Those teams remain responsible for care within their respective settings.
The potential Alderon role begins where longitudinal outpatient care is needed: understanding the recent episode, reconciling medications, addressing chronic and preventive needs, following recovery, coordinating referrals and testing, and helping patients understand the next step.
Ongoing care may include
- Post-discharge clinical follow-up
- Medication reconciliation
- Chronic-condition management
- Laboratory follow-up
- Preventive-care review
- Specialist and diagnostic coordination
- Recovery monitoring
- Escalation when a higher level of care is needed
Transitional Care
The first days after discharge can shape what happens next.
Patients may leave a facility with several immediate responsibilities: obtain new prescriptions, stop old medications, schedule testing, arrange specialist visits, monitor symptoms, understand activity restrictions, and recognize warning signs.
Alderon’s transitional care model is designed to help appropriate patients make that transition more deliberately and then move back into longitudinal primary care.
Transition follow-up may address
- Discharge-document review
- Medication reconciliation
- New or changing symptoms
- Pending laboratory or imaging results
- Specialist appointments
- Home monitoring
- Recovery goals
- Return precautions and escalation
Professional Referral Connections
Connect this partnership model to the right referral pathway.
Alderon’s B2B pathways are organized so that facilities, discharge teams, and other professional partners can find information that matches the role they play in a patient’s transition.
Referral Partners
Explore Alderon’s broader professional and organizational referral pathways.
View referral partnerships Hospital & Care CoordinationCase Managers & Discharge Planners
A dedicated pathway for professionals arranging post-discharge follow-up and outpatient continuity.
View case-management pathway Clinical ServiceTransitional Care
Review the patient-facing clinical service designed to reconnect discharge plans with longitudinal primary care.
View transitional carePartnership Model
A referral pathway built around clear responsibilities.
Any facility or community partnership would be developed around defined eligibility, secure referral processes, communication expectations, clinical scope, privacy, payment structure, escalation responsibilities, and state-specific availability.
Define the need
Identify the population, geography, transition challenges, expected referral volume, and services the organization is trying to support.
Establish the pathway
Determine appropriate patient eligibility, documentation requirements, referral workflow, communication responsibilities, and escalation processes.
Connect the patient
Eligible adults can be directed into Alderon’s secure onboarding or referral workflow for evaluation and establishment of care when the service is available in their location.
Continue primary care
Once established, appropriate patients can move from transition-focused follow-up into ongoing preventive, chronic, medication, and general primary care.
Alderon’s public WordPress website is informational and is not used to collect protected health information. Patient-specific records, diagnoses, medications, discharge summaries, referral documentation, and other sensitive clinical information should be transmitted only through a secure workflow specifically designated by Alderon.
Telehealth & Local Care
Virtual access should support the local care ecosystem.
Alderon is telehealth-first, but not every medical need can or should be managed virtually. Facility primary care works best when telehealth is used as one component of a broader care network.
Local laboratory testing
Laboratory testing can be coordinated locally when clinically indicated and reviewed as part of the patient’s ongoing care plan.
Diagnostic imaging
Imaging can be ordered or coordinated when appropriate, with results incorporated into clinical follow-up.
Specialists and rehabilitation
Patients may need specialty physicians, physical or occupational therapy, home-health services, or other local resources beyond Alderon’s direct scope.
In-person or emergency evaluation
When symptoms require hands-on examination, urgent testing, emergency treatment, or hospitalization, patients are directed to the appropriate local level of care.
Availability & Scope
Partnership details are defined before implementation.
Facility and community programs are developed individually.
Alderon Medical is developing this service model as an extension of its telehealth-first primary-care platform. Organizations interested in a potential partnership can discuss patient population, service area, referral needs, workflow, contracting, and implementation.
This page does not represent that Alderon currently holds contracts with any particular hospital, skilled nursing facility, long-term care organization, assisted-living community, long-term acute-care hospital, rehabilitation facility, community organization, or health system.
Available services depend on clinician licensure, organizational readiness, patient location, clinical appropriateness, payer or payment arrangements, and the final terms of any partnership.
Alderon does not provide emergency response, continuous bedside coverage, facility nursing services, inpatient attending services, or 24/7 monitoring through this program unless separately and explicitly established in an applicable future agreement.
Facility & Community Care
Build a better bridge from facility care back to longitudinal primary care.
Skilled nursing, long-term care, rehabilitation, assisted-living, hospital, post-acute, case-management, and community partners interested in future primary-care pathways can contact Alderon to discuss population needs, geography, secure referral workflow, scope, and potential program design.