TRANSITION CARE PROGRAM
The Transition Care Program (TCP) offers a one-on-one patient engagement approach to ensure a patient’s transition from an acute care hospital to their home, or place of care, is cohesive and seamless for a period of 30 days post discharge.
The primary goal of the Transition Care Program (TCP) is to coordinate required clinical services post discharge, remove any barriers that impact accessing timely follow up care and foster patient compliance with discharge orders to improve quality outcomes. The key component to the success of the TCP program is having a comprehensive focus that addresses both the medical and social aspects (Social Determinants of Health) the patient may face.
With the Transition Care Program (TCP), IHD collaborates directly with the acute care facility. Patient engagement begins at the time of hospital admission notification. Continued high touch, patient centric support services such as primary care provider follow up, specialist appointments, durable medical equipment and prescription needs are coordinated for up to 30 days from the date of discharge, Ultimately, the goal of the TCP program is to connect patients with the appropriate outpatient provider setting, caregiver, provider (s) and community resources resulting in increased patient compliance, reduced hospital/ER utilization and improved patient outcomes.