For transition-of-care teams

Follow-through after discharge.

Baba advocates handle the calls, coverage, equipment, and follow-up that start when a patient goes home.

A transition-of-care nurse reviews a discharge plan with an older patient and his daughter

Send the open tasks. Get a useful update.

Baba contacts the patient, works the coordination tasks, and returns a concise summary to your team.

A Baba advocate coordinates follow-up work by phone

Designed to sit alongside the referral systems your team already uses

PointClickCare
CarePort powered by WellSky
MatrixCare

Patient reached

The advocate confirms coverage, consent, and the work that still needs an owner.

Tasks worked

Equipment, follow-up visits, transportation, and benefit questions move forward.

Update returned

Your team sees what was completed and what still needs clinical review.

Close the gaps that open after discharge

Your transitions team sets the clinical direction. Baba carries the coordination work that determines whether the plan actually reaches home.

Medication, coverage, and authorization barriers

The advocate tracks coverage requirements, gathers available documentation, follows the insurer or pharmacy, and routes clinical questions back to the treating team instead of interpreting the plan.

Equipment and post-acute services

A discharge order only helps when the supplier accepts the plan, the documentation is complete, and delivery happens. The advocate works those handoffs and returns exceptions to the right owner.

Appointments, transportation, and home barriers

Follow-up access, rides, food, benefits, and caregiver questions can derail a sound plan. An advocate makes the calls, documents what changed, and escalates anything that needs clinical review.

Mr. Alvarez leaves the hospital on a Friday

In this illustrative transition, his discharge plan is clinically sound. By the time he gets home, the walker, medication list, transportation, and follow-up still need owners.

Friday

The referral reaches Baba

The transitions team sends the referral. With his consent, an advocate reviews the discharge instructions and confirms the work that still needs an owner.

Monday

The missing walker gets an owner

The advocate locates the order, checks the required documentation, and coordinates with a supplier that accepts his plan.

Tuesday

A medication question goes to the clinician

One instruction does not match the medication list. The advocate routes the discrepancy to the treating team without interpreting or changing the plan.

Thursday

The follow-up is on the calendar

The visit is confirmed, transportation is checked, and Mr. Alvarez has the questions he wants to bring to the appointment.

One week later

The transitions team gets the useful update

With consent, Baba returns a concise note: what was completed, what remains open, and the medication question waiting for clinical review.

Your team keeps the clinical plan.

Baba extends the transition plan into the home without stepping into diagnosis, treatment, or the relationship between the patient and their clinicians.

Clinical decisions stay with the treating team

Advocates do not diagnose, prescribe, interpret symptoms, or change discharge instructions. Clinical questions return to the appropriate clinician.

Work begins with consent

Patients choose who Baba may contact and what information may be shared. Coordination follows that permission.

Updates return to your transition workflow

Consented updates can return by fax or portal with completed tasks, open barriers, and anything that needs clinical review.

Practical answers before the handoff

2 days average time to consultation
$0 out of pocket for most eligible clients
How coverage works
27+ average years of healthcare experience for advocates

Questions from transitions-of-care teams

The practical details behind a discharge referral, patient consent, and the update back.

Transitions-of-care nurses, discharge planners, care managers, social workers, physicians, and other authorized clinical team members can start a referral. The referral flow collects the information Baba needs to contact the patient and confirm next steps.

Talk through your transition workflow

Share where post-discharge work is still falling through. We will follow up about fit, consent, referral timing, and how Baba can return updates to your workflow.

What best describes you?

Do not include patient names or health information in this form. Use the referral flow for clinical referrals.

Get bandwidth back

Refer a patient or talk with us about your transition workflow.