How it Works
Every healthcare situation is different, but the process doesn’t have to feel complicated.
Right Time Care Partners provides a clear, structured approach to understanding what’s happening, identifying what matters most, and determining the right next steps.
For Healthcare Organizations:
We work alongside your team to identify opportunities, define priorities, implement a focused approach, and measure the outcomes that matter to your organization
Assessment & Clarification
About:
We begin by understanding the current situation, including the medical condition, care setting, recent events, concerns, and questions that may not yet be fully addressed. The goal is to create a clear, accurate picture of what is happening before determining next steps.
For healthcare partners, this may include a structured case review to identify clinical, operational, and utilization concerns.
What to Expect:
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Review of the current situation and relevant information
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Identification of key concerns, unanswered questions, and immediate priorities
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Review of available medical records or discharge information, when appropriate
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Clear understanding of what needs attention next
Alignment of goals
About:
Once the situation is clearly understood, we focus on what matters most. This includes identifying the patient’s values, preferences, and priorities while clarifying available options and potential trade-offs. The goal is to support decisions that are both medically appropriate and personally meaningful.
For healthcare partners, this step supports earlier, more effective goals-of-care conversations and helps reduce crisis-driven decision-making.
What to Expect:
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Clarification of goals, values, and priorities
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Review of available options and important considerations
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Advance directive review or guidance, when appropriate
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A clearer framework for making informed decisions
Action Plan
About:
With a clear direction established, we help turn clarity into action.
This may include coordinating services, preparing for conversations with providers, supporting transitions in care, or connecting you with appropriate resources.
For healthcare partners, this may support clearer discharge planning, stronger care transitions, and better coordination across settings.
What to Expect:
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A clear action plan and next steps
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Support preparing for healthcare conversations and care transitions
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Coordination guidance, when needed
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Referrals and connections to appropriate resources
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 helps patients, families, and care teams feel supported as circumstances change.
For healthcare partners, ongoing support can help maintain alignment, strengthen care planning, and identify concerns before they become crisis-driven decisions or avoidable transitions.
What to Expect:
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Follow-up as needs or circumstances change
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Updated next steps and priorities, when needed
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Continued guidance and resource connections
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Support with new questions or decisions as they arise
Organizational Impact
Right Time Care Partners supports healthcare organizations in:
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Reducing avoidable hospitalizations and readmissions
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Improving the 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 the patient, family, and provider experience
Our approach is designed to support measurable improvements in utilization, care alignment, and the 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.