Transitions of Care (TOC) programs are designed to provide continuity of care to patients
as they move from the hospital to home or other care settings.
Transitions of Care utilizes components of evidenced based transitional care models to
assist with the provision of seamless care across the health care continuum, improve
patient outcomes, and induce financial savings. A multidisciplinary approach, staffed
with registered nurses, licensed social workers and healthcare professionals, synchronizes
the transitions of care prior to admission, during the hospitalization and after discharge.
Screening and identification of barriers and strengths and the promotion of patient /
family engagement towards addressing obstacles to obtainment of optimal health are
hallmarks of the department.
Services of the Transitions of Care department are available 24/7 to all inpatients
and outpatients of Hendricks Regional Health.
WHERE WILL YOU FIND THE TRANSITIONS OF CARE TEAM?
In the Pre-Op Office
- Pre-admission planning for scheduled surgeries
In the Emergency Department
- Community Resources
- Psychiatric and chemical dependence assessments and referrals
- Abuse, neglect and assault assessments and referral to services
On the Inpatient Units (Medical, Surgery, Pediatrics, Labor & Delivery)
- Assessment of the patient’s and family’s social and emotional environment and
ability to cope with the current situation
- Community Resources,
- End of Life care discussion and advance directives
- Resolution of financial concerns related to insurance coverage, cost of hospitalization
or medical needs, or income loss due to illness or injury
- Long and short-term care planning after hospitalization
- Counseling and emotional support needed as a result of the many stresses created
by the adjustments and lifestyle changes necessitated by illness and hospitalization
- Adoption assistance
- Support Groups
In the HRH Oncology Center
- Assessment of the patient’s and family’s social and emotional environment and
ability to cope with the current situation
- Community Resources and Support Groups
- End of Life care discussion
In the Transitions of Care Office