Transitional Care Program

The Transitional Care Program standardizes the process for all patient care. This program focuses on patient communication, improved long-term outcomes, and reduction in re-hospitalizations. This model is based on four pillars:

1. Medication self-management,
2. Follow up with PCP/Specialist,
3. Use of Personal Health Record and
4. Knowledge of red flags/warning signs/symptoms and how to respond.

PATIENTS MUST QUALIFY FOR PROGRAM

Those who qualify for this program must meet at least one of the following criteria:

• Primary diagnosis of heart failure, pneumonia, COPD or AMI, or
• 75 years or older, or
• Eight or more medications, or
• Recent hospitalization(s), or
• Three or more chronic diseases

PATIENT BENEFITS/SERVICES

• Emphasizes coordination and continuity of care, prevention and avoidance of complications and close clinical treatment and management
• Clinician visits patient daily in hospital and begins process of medication management and assures physician follow up
• Coordination with facilities, physicians, the patient and their family
• Comprehensive in-hospital planning and home follow up
• Post discharge Transitional Care Coordinators maintain contact with patient to assure continued compliance and stabilization

DOCTOR BENEFITS

• Thorough physical assessment
• Comprehensive case management including a single point of contact
• Care is delivered and coordinated by the same clinicians in hospitals, SNFs and homes, seven days per week using evidence-based protocol with a focus on long-term outcomes
• Physician protocol compliance
• Focus on optimal outcomes
• Single point of contact for coordination of service and reporting