The Transitions of Care (TOC) program provides continuity of care for patients discharged from UVA Health Medical Center to a partner Skilled Nursing Facility (SNF). The program aims to establish relationships with patients and families discharged to a facility to promote safe discharge plans, address medication reconciliation, empower patient self-efficacy, reduce ED visits and readmissions, decrease length of stay, lower health utilization costs, and improve continuity of care.
Each patient is assigned a liaison who works with the discharging inpatient LIPs, care management, patient, and skilled nursing facilities. The program seeks to reduce subsequent ED visits, readmissions, and length of stay and to promote and provide education and family support services.
The program also enhances the effective collaboration and communication between UVA Health and facilities admitting patients for skilled and/or long-term care services.
TOC evolved from a Medical Center coalition focused on improving patient progression and throughput. The program is provided throughout the University of Virginia Medical Center for adult patients who meet eligibility criteria. Additionally, hospice and palliative care initiatives are supported through the Transitions of Care program and work closely with the Office of Advance Care Planning.
Expansion to other facilities is expected within 2025-2026. Current SNF partners are Albemarle Health & Rehab, Charlottesville Health & Rehab, Monroe Health & Rehab, The Laurel, and The Cedars.
