Post Acute Specialists (PAS) is a physician-led medical group pairing a trained Transitional Care Coordinator (TCC) at home with a PAS clinician by telehealth. The TCC assists with vital signs and visit participation; the clinician assesses recovery, reviews medications and discharge instructions, and shares recommendations with the established care team.

Follow-up typically occurs within 72–96 hours, subject to clinical needs, referral timing, and availability. PAS complements primary care and care management by addressing gaps after discharge. For ACOs and health plans, earlier identification of recovery concerns and care gaps may help address avoidable emergency visits, readmissions, and total cost of care.