How it Works
Right Time Care Partners provides a structured, step-by-step approach designed to bring clarity, alignment, and confident decision-making to complex healthcare situations.
For Healthcare Organizations:
Our approach supports care teams in improving patient alignment, reducing avoidable utilization, and strengthening care coordination across settings.
Assessment/Q&A
About:
We begin with a comprehensive assessment of the current situation. This includes understanding the medical condition, care setting, recent events, and the questions or concerns that may not yet be fully addressed. This step is focused on clarity ensuring we have a complete and accurate picture before moving forward.
For healthcare partners, this includes structured case review to identify clinical, operational, and utilization risks.
Documents:
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Intake summary (completed from consult)
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Key concerns and current state summary
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Optional: medical records or discharge summaries (if provided)
Alignment of goals
About:
Once the situation is clearly understood, we focus on aligning care with what matters most. This includes identifying patient values, preferences, and realistic outcomes while clarifying available options and trade-offs. The goal is to ensure decisions are not only medically appropriate, but personally meaningful.
For organizations, this step supports earlier and more effective goals-of-care conversations, improving patient alignment and reducing crisis-driven decision-making.
Documents:
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Goals-of-care summary
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Advance directive review or guidance
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Decision framework or recommendation outline
Implementation
About:
With a clear direction established, we support next steps. This may include coordinating services, guiding conversations with providers, preparing for transitions in care, or ensuring the right resources are in place. This step turns clarity into action.
For healthcare teams, this translates into clearer discharge planning, improved care transitions, and reduced fragmentation across settings.
Documents:
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Action plan / next steps checklist
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Care coordination recommendations
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Referral or resource guidance
Ongoing support
About:
Healthcare situations evolve. We remain available to provide continued guidance as needs change, new decisions arise, or additional support is needed. This ensures patients, families, and care teams are not navigating these moments alone.
For organizations, ongoing support helps sustain alignment, prevent avoidable readmissions, and reinforce consistent care planning practices.
Documents:
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Follow-up notes or updated recommendations
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Ongoing care plan adjustments
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Resource updates as needed
Organizational Impact
Right Time Care Partners supports healthcare organizations by:
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Reducing avoidable hospitalizations and readmissions
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Improving timeliness and quality of goals-of-care conversations
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Strengthening discharge planning and care transitions
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Supporting alignment with CMS priorities and value-based care models
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Enhancing patient, family, and provider experience
Our approach is designed to support measurable improvements in utilization, care alignment, and overall care experience.
Glossary of terms
Advance Directives
Legal documents that outline a person’s preferences for medical care if they are unable to communicate their decisions.
Goals of Care
Conversations and decisions that define what matters most to a patient in relation to their health,
treatment, and quality of life.
Care Coordination
The process of organizing patient care activities between providers, services, and settings to
ensure safe and effective care.
Care Transitions
Movement between healthcare settings, such as hospital to home, hospital to rehabilitation, or to long-term care.
Level of Care
The type and intensity of medical services a patient needs (e.g., home care, hospice, hospital, skilled nursing).
Readmission
When a patient returns to the hospital within a short period after discharge, often within 30 days.
Palliative Care
Specialized medical care focused on relief from symptoms and stress of serious illness, appropriate at any stage of illness.
Hospice Care
Care focused on comfort and quality of life when curative treatment is no longer the focus.
Surrogate Decision Maker
A person authorized to make healthcare decisions on behalf of a patient if they are unable to do so.
Advance Care Planning (ACP)
The ongoing process of discussing and documenting preferences for future medical care.
Avoidable Utilization
Healthcare services, such as emergency visits or hospital admissions, that may be preventable with earlier intervention or better care alignment.
Value-Based Care (VBC)
A healthcare delivery model focused on improving patient outcomes while managing cost and resource utilization.
Care Alignment
Ensuring that treatment plans, provider actions, and patient goals are consistently aligned across
all care settings.