A Fully Managed Transitional Care Model
At No Cost to Your Organization
Rapid Referral Activation
Patients enrolled in 24–48 hours
In-Home or Virtual Visit
Within 7 days by our licensed NP
RPM + CCM Ongoing Support
Monthly engagement & monitoring
Medication reconciliation
Symptom tracking & escalation
Monthly reports to PCPs
A Simple, Proven Workflow That
Keeps Patients Connected
Referral from hospital/ED
RPM + CCM enrollment within 48 hrs
NP completes in-home or telehealth visit
Day 14: Refill & adherence check
Day 21: PROMs + escalation if needed
Day 30+: Continued care via RPM & CCM
We’re Your White-Labeled Care Team
Clinical, Cultural & Scalable
Full-service care delivery from referral to chronic management
You bill Medicare/MA — we do the work
Integrated CRM + eClinicalWorks reporting
Bilingual, culturally competent staff
No upfront cost, devices, or staffing overhead
Your Patients Stay Home.
Your Revenue Grows.
You bill under your NPI
HiYH submits superbills monthly
Split revenue model
Outcomes at a Glance
Enrollment
95%
NP visit compliance
85%
Med adherence
↓20-25%
Readmissions
We’re Now Onboarding Florida
Partners for Fall 2025
Get started in as little as 3 weeks. We provide onboarding, referral materials,
staff training, and tracking tools to make it easy.
staff training, and tracking tools to make it easy.