Transitions of Care

In order to deliver timely, appropriate transitional care, primary care providers (PCPs) and other outpatient providers must know when their patients are discharged from the hospital and related information. THN has developed the transitions of care process for network providers who collectively oversee care for nearly 200,000 patients.

 Once patients are discharged from the hospital to home, a skilled nursing facility or other locations, coordinated follow-up care is critical to reducing hospital readmissions and optimizing patient outcomes. PCPs are responsible for facilitating a comprehensive range of care, including medications and treatments, care coordination among specialists and many other issues patients face on their road to recovery.

With THN’s transitions of care process, our participating providers can use a transitions of care tool, which provides a daily patient discharge report, so they know what brought patients to the hospital, when they were discharged and their condition upon discharge. At certain locations, a staff member can be assigned to call patients within two business days of discharge and schedule a follow-up appointment within one to two weeks of discharge. They review medications, answer questions and closely follow the patients during the 30-day post discharge window.

To facilitate high quality of care, THN tracks a variety of transitions of care touchpoints, including patient access to same day and after-hours appointments, referrals and cost and utilization of services. In addition, we offer an integrated, team-based approach via tools, training and other support.