AnsibleHealth
Interested patients

Fewer 30-day readmissions, with your clinicians in charge.

We pick up your highest-risk heart, lung and sepsis patients at discharge, carry out their doctors' plan at home, and send them back to the clinicians who already care for them.

Talk to our team
A nurse on a headset at her desk in the evening, a patient's readings on her laptop

After your patient goes home.

You refer at discharge

A straightforward order at discharge planning. There is nothing new for your staff to run.

We call and check the details

We contact the patient, reconcile the discharge medicines against what they took before, and confirm oxygen, equipment, home health and follow-up visits.

We stay close

We review home readings every day and answer day or night, so a problem is treated early, at home.

They come back to you

Patients keep their appointments with your clinicians, and your clinicians hear from us at every change.

What we take on.

Your clinicians set the plan. We do this between their visits.

We watch and respond

  • Early detection Home vital signs reviewed every day, with alerts for hospital and ER visits and for missed refills. A clinician reviews every flag.
  • 24/7 call support Your patients reach a clinician day or night: their own team by day, our on-call team with physician backup after hours.
  • Acute issue management COPD: action plans and rescue packs to intercept exacerbations. Heart failure: volume tracking and proactive diuretic management.

We treat

  • Medication optimization GOLD-aligned for COPD and the four GDMT pillars for heart failure, titrated to treatment doses, with adherence, refills and prior authorizations handled.
  • Comorbidity management Heart failure and COPD together, with diabetes, kidney disease and sleep apnea, alongside the PCP. Cancer screening and vaccines kept current.
  • Continuous management The same four to six clinicians for each high-risk patient, daily rounds and about 30 clinical contacts a year, for as long as the patient needs it.
  • Specialists when there are none If your patient has no cardiologist or pulmonologist, ours provide that care and you stay informed.

We carry out your plan

  • Transitions of care After a discharge or an ER visit we contact the patient, reconcile the medicines against the prior regimen, and confirm oxygen, equipment, home health and follow-up visits.
  • Care plan execution Your plan carried out between visits: labs and imaging arranged, referrals made, appointments kept.
  • Reports back to you The care plan at enrollment, a note at every medication change, ER visit, admission and discharge, and a monthly summary.
  • DME and supplies Oxygen, CPAP, nebulizers and home sleep studies ordered and followed up. Each patient gets a monitoring kit with its own cellular connection.

We look after the patient and family

  • Patient education Respiratory therapists teach the disease, symptoms, and inhaler technique or diet, one to one and in small groups.
  • Smoking cessation Counseling, with varenicline or nicotine replacement prescribed by our clinicians.
  • Support group Peer support groups and group sessions. For homebound patients it is some of their only social contact.
  • Caregivers Named at the start, taught what to expect and what is concerning, and called at every escalation.
  • Cardiac and pulmonary rehab A 36-session home-based program, up to five days a week.

We work alongside your clinicians.

Your doctors set the direction.

Your pulmonologists, cardiologists and primary care physicians stay in charge of the plan. We carry it out at home between visits, and send findings back with the reason and the urgency.

Patients come back to you.

We get patients back to their appointments, stronger. One patient who had stopped seeing her doctors now goes to every primary care and specialist visit.

Nothing new for your staff to run.

Referral is a straightforward order at discharge, implementation is flexible, and there's no cost to the health system and little or none to the patient.

Short on specialists? Ours fill in.

Where you don't have the cardiologists or pulmonologists, ours become the specialists, and our care team takes your patients' calls 24/7.

A physician and a nurse going over a patient's chart together

Sepsis Recovery Program.

A 40–60 day program for patients going home after a sepsis hospitalization, built to cut 30-day readmissions. You refer at discharge planning, and a nurse practitioner does the first visit: history and physical, medication reconciliation, and a care plan.

  • A home kit with a blood pressure cuff, pulse oximeter, and thermometer, with daily vitals
  • Three check-ins the first week, two the second, then weekly
  • Medication adherence support and early escalation when vitals turn
  • Patients graduate, or move into longer-term care if they need it
A daughter on the phone with the care team, beside her mother at home

Let's talk about your readmissions.

Email partnerships@ansiblehealth.com and we'll walk you through how referral and the programs would work for your patients.

Talk to our team