The Problem Patients are sent home with a difficult to digest care plan, while dealing with a “new normal,” and navigating a complex care environment. It is hard for them to fully comprehend which resources they need while returning to health. Current remote care models leverage phone or online surveys to gauge adherence to care plans, while others use patient monitoring devices delivering data to a base station, and nurses reactively investigate out of threshold events. Nurse resources are often limited, and the patient engagement model can suffer at the expense of clinical priorities. Welcome Home Health (WHH) Solution WHH shifts the model, serving as the virtual in-home extension of the patient’s clinical care team assisting in the implementation of, and adherence to the care plan. WHH provides direct patient/client access to a highly trained Health Advocate (HA) who ensures observance of patient and diagnosis-specific care plans and bridges communication between patients/caregivers and their clinical providers. The HA serves as the single point of contact for care plan, discharge order, coordination. WHH pharmacist conducts a medication review and reconciliation within 36 hours of patient onboarding. In addition to daily virtual visits, WHH is available 24/7 for on-demand patient access for episodic needs. WHH develops custom levels of care transition services for our clients based on their requirements and areas of improvement/focus. Our service suite and technology include the following: • Perform clinical patient triage • Facilitate connections between providers & patients • Connect to home health, DME, pharmacy, community resources and transportation as needed • 24/7 patient access to a HA up to and including 911 calls • Deliver data directly into client EMR or deliver via API through client comprehensive care platforms as desired • Complete patient engagement model integrating remote patient monitoring