Introducing Transition Management Teams

For patients who require extra support when leaving the hospital, OneCity Health recently conducted an initial training for our first group of interdisciplinary Transition Management Teams. These teams work closely with hospital staff to create a comprehensive plan for our patients who are at a high risk of returning to the hospital within weeks of leaving. Pilots for our Care Transitions project, which we previously detailed, occur within the inpatient setting of four OneCity Health partner hospitals.

The Transition Management Team visits a patient identified by the inpatient care team while he or she is still in the hospital and determines if the patient could benefit from additional support over the critical 30 days following discharge. Support may include calling patients within 48 hours of leaving the hospital, assisting them with obtaining medications or ensuring follow-up occurs with a physician. The Transition Management Team also identifies and refers patients for any longer-term care management needs.

For our Transition Management Teams to be successful, it is essential for hospital staff to identify and refer patients who require extra support to stay healthy after leaving the hospital. Additionally, we need to strengthen the provider network that supports our patients’ transitions from the hospital to the community. As our pilot efforts mature, we will begin to incorporate our community partners into this work.

We will discuss the referral criteria in more detail soon. If you have questions in the meantime, please email DSRIPSupport@nychhc.org with the subject line “Care Transitions”.