The Transitions of Care (TOC) program represents a liaison between the discharging inpatient LIPs, care management, patient, and skilled nursing facilities. The program seeks to reduce subsequent ED visits, repeat admissions, and length of stay; and to promote and provide education services. The program also serves to enhance the collaboration between UVA Health and facilities that are admitting patients for skilled and/or long-term care services.
TOC developed from a coalition focused on patient progression. It is currently provided throughout the University of Virginia Medical Center for adult patients who meet eligibility criteria. The goal of the program is to establish relationships with patients who are discharging to a facility with the aim of promoting safe discharge plans, addressing medication reconciliation, empowering patient self-efficacy, reducing ED visits and readmissions, decreasing length of stay, lowering health utilization costs, and improving continuity of care.
