As part of our holistic patient-centered approach to care, Essen Medical Associates has launched a Transition of Care (TOC) Program to ensure the seamless coordination of care and care delivery for all of our patients following their discharge from the hospital, nursing home or rehabilitation facility back in to their home. Our TOC Program is a focused intervention in which we track patients for 30 days following discharge, during the critical time period when they are most likely to develop complications, in order to reduce hospital re-admission and help speed patient recovery.
Key Program Components:
- Telephonic follow-up pre- and post-discharge
- Face-to-face visits post-discharge
- Medication reconciliation
- Medication refills and adherence
- Caregiver support
- Fall risk reduction
- Scheduling and coordination of follow-up appointments with PCPs and others
- Palliative/hospice assessment
- Regular communication with patient’s medical team
This approach has previously shown to be successful in reducing the rate of avoidable re-hospitalization of some of our most chronically-ill patients
Please make sure to contact us at (718) 58-ESSEN if you are being hospitalized or admitted to a nursing home so that we can follow up on your care.