FOR HOspitals and Health Systems
Partnering with Hospitals to Improve Patient Outcomes and Reduce Utilization
Become a Pair Team Partner
‍Pair Team is a dedicated in-house medical group that helps hospitals support high-risk patients post-discharge. We specialize in Enhanced Care Management (ECM) and care coordination, ensuring patients receive the medical and social support they need—at no cost to the hospital or patient.
  • Reduce Avoidable Readmissions & ED Utilization
    We provide longitudinal care coordination for frequent ED and inpatient utilizers, improving care continuity and preventing unnecessary hospital visits.
  • Ensure Safe Transitions & Improve Patient Follow-Up
    ‍    Our team ensures warm handoffs from hospital to home, connecting patients to primary care, behavioral health, and community resources.
  • Improve Quality Metrics & Health Outcomes
    With a 58% reduction in avoidable ED visits and 52% improvement in diabetes control, our ECM program is proven to drive better outcomes.

How Pair Team Works with Hospitals

We integrate into your hospital’s discharge workflow to identify and enroll eligible patients before they leave your facility.

Virtual Hand-Off

In-Person Hand-Off (Embedded)

Patient Self Service

Hospital staff identify Medi-Cal patients who qualify for ECM (e.g., homelessness, mental illness, substance use, frequent ED use).
Pair Team can embed a staff member on-site to support hospital teams with patient eligibility, enrollment, and referrals.
Pair Team will equip frontline hospital staff with educational materials to help patients understand their eligibility and easily enroll in the program themselves.
Staff contacts Pair Team’s dedicated ECM hotline, ensuring an immediate connection before discharge.
This liaison assists with care coordination without requiring clinical credentialing.
Hospital staff can also provide patients with the enrollment form directly, making it easy for them to sign up for support.
We engage and enroll the patient, coordinating ongoing medical and social care post-discharge.
We engage and enroll the patient, coordinating ongoing medical and social care post-discharge.
We engage and enroll the patient, coordinating ongoing medical and social care post-discharge.
58%
Reduction in
Avoidable ED Visits
21%
Increase in Primary
Care Utilziation
52%
Of Uncontrolled Diabetics
Achieved Control
57%
Depression Remission
Rate

Whole-Person Support for High-Needs Patients


Pair Team acts as an extension of your hospital’s care team, ensuring that high-risk patients receive ongoing, wraparound support after discharge. Our integrated approach combines clinical care, social services, and technology-driven coordination to improve outcomes and reduce unnecessary hospital visits. By addressing both medical and social determinants of health, we help stabilize patients and connect them to the long-term care they need. Here’s how we support your hospital and your patients:

  • In-house medical team (NPs, RNs, LCSWs, CHWs) managing complex care

  • Social-first model integrating housing, food, and behavioral health support.

  • Tech-enabled care coordination to track patient engagement and outcomes.

“The Enhanced Care Management (ECM) program requires new staff, workflows, and tooling. I could not participate in ECM without Pair Team. They do everything, including hiring, training, and reporting!” 

Azer Rezk
CEO, Metropolitan Clinics

Join the Pair Impact Network. Contact us to get started.

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