Transitions of Care

To ensure timely and appropriate transitional care, primary care providers (PCPs) and other outpatient clinicians must be promptly informed when their patients are discharged from the hospital. They also need access to relevant clinical information to support post-discharge care planning.

The structured transitions of care process for THN’s network providers, who collectively manage care for nearly 200,000 patients, focuses on patients discharged from inpatient setting who are at the highest risk for readmission.

Once patients are discharged to home, coordinated follow-up care becomes critical. PCPs play a central role in managing medications, coordinating with specialists, and addressing the complex needs patients face during recovery. THN offers a team-based, integrated approach supported by tools, training, and ongoing provider support.

Through the Transitions of Care program, participating providers receive clinical documentation from a registered nurse that includes the reason for hospitalization, discharge date, the patient’s condition at discharge, and assessment of the patient’s transitional care needs and related interventions and recommendations. Designated Transitions of Care staff contact patients within two business days, review medications, answer questions, and monitor the patient closely with at least a weekly call during the 30-day post-discharge period.

To support high-quality care, THN tracks key transitional care metrics, including access to same-day and after-hours appointments, referral patterns, and service utilization.