Transition of Care (TOC)

Transition of Care (TOC) Program

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 718.294.5600.