Our Transition of Care (TOC) program is a 30-day post-discharge management program designed to help patients transition back into the community following hospitalization or nursing home admission. Patients are followed for 30 days – starting from the date of discharge – during the critical time period when they are most likely to develop complications that lead to avoidable re-admissions. During the 30-day period, patients receive vital medical care through in-home provider visits and regular telephonic follow-ups. TOC will also coordinate a variety of services necessary to ensure patients recover quickly and remain safely in their homes. Following completion of the 30-day TOC period, patients who have sufficiently recovered are redirected back to the care of the regular primary care providers. The goal of TOC is to help recently-discharged patients avoid unnecessary hospital and emergency room re-admissions while ensuring quick healing and recovery right at home.
Our TOC program includes the following high-quality, comprehensive services: High quality in-home medical care Caregiver support Collaboration and communication with patient’s primary care provider, specialist and discharging hospital Coordination and expedited implementation of necessary additional home care needs including skilled nursing, physical/occupational therapy, and durable medical equipment & supplies Discharge summary review Lab testing & diagnostic imaging Medication reconciliation & adherence Patient & family education Prescription writing, orders, refills and home-delivery Referrals for specialists, home attendants, home health aides and visiting nurse service Transportation coordination For more information, coverage options, to schedule an appointment, or to refer a patient, please call 718-294-6200