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CORE Population Health Management

Follow Up Post Hospitalization

Comprehensive support for critical periods of transition between care settings

For high risk, high need individuals

For those with complex medical needs, our coordinated approach to transitional care prioritizes member stability and consistent engagement with their providers, reducing the likelihood of members getting lost in transition.

During this critical time of increased risk for complications or readmission, our team helps ensure transitional care aspects such as care coordination, medication management, education, social and emotional support, and follow-up care are patient-centered and as smooth as can be.

Medical Checkup
  • Identify complications early, in-person

  • Improved outcomes

  • Increased engagement with providers

  • Higher quality of care

  • Improved use of resources

Key Features

Rapid member support before and after discharge

Assess and coordinate care to reduce re-admission risk

Addresses the
full Health Triangle

Meet social, behavioral, and physical health needs

Value-based contract with shared risk and savings

Member connectivity technology

Reinforce engagement with community-based provider

Executed by an integrated
healthcare team

Real-time and All-time access to non-emergency help


At Catalytic Health Partners we take social and behavioral needs beyond the “basics” to ensure stability so that medical needs can be achieved.


Catalytic Health Partners includes mental health services and clinical encounters by credentialed providers support MLR.

Michelle L, Member

“The CHP team opened doors for me that were closed before so I could get the care I needed.”
Modern Architecture

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How can we help?

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