Family doctors have historically been charged with handling post-discharge care. These providers are expected to know their patient has been discharged from a hospital, reach out to them, and meet their transitional needs—all before they are able to see the patient for a visit. Understandably, the majority of primary care offices have been overwhelmed by the increasing acute and chronic needs of these patients.Case managers in hospital, inpatient rehab, and outpatient practices agree that care during the transition from hospital discharge is a critical service that is currently not being met to current needs. When we can meet those needs, we lower hospital readmission rates and increase the quality of patient outcomes. Patients leave the hospital without overlapping care and are often left confused, feeling unsupported, and are more prone to readmissions. This is especially true for patients with complex medical histories or those who have had a life-changing health event. A strained and complicated health system also leads to higher risk of medical errors.BridgeCare offers a referral-based service between medical facilities called The Hospital to Home Clinic. H2H Clinic offers a link between inpatient and outpatient care, provided by a physician who has experience with both. BridgeCare also offers Physicians on Call for patients with high-risk chronic diseases. Devices, daily monitoring and physician oversight and help with management is offered to patients in the effort to prevent avoidable poor outcomes and hospitalizations.