Transitional Care Services

Jane Phillips Transitional Care Services provides education and referrals to appropriate community resources in order to improve health outcomes for the patients, and reduce hospital readmissions for the same or similar conditions during the 30 days post discharge.

The Transitional Care department will see select patients after discharge from one of the following hospital settings:

  • Inpatient acute care;
  • Inpatient psychiatric unit or hospital;
  • Long Term Care Hospital (LTAC);
  • Skilled Nursing Facility (or swing bed);
  • Inpatient Rehab, or
  • Outpatient Observation.

To qualify for these services, the patient must not only be discharged from one of the above settings, but the patient must be discharged to a community setting, such as:

  • Personal home;
  • Home of family or friend;
  • A rest home (nursing home, long term care); or
  • Assisted living.

Services are provided under the direct or indirect supervision of a physician or a non-physician practitioner (NPP) such as a Clinical Nurse Specialist, Nurse Practitioner or Physician Assistant.  JPMC's current Licensed Clinical Staff (Social Worker, RN, Pharmacist, Dietitian, etc.) will work closely with the physician or NPP to furnish most of the services needed such as: 

  • Review discharge information, focusing on medication reconciliation and medication education;
  • Review need for follow-up on pending diagnostic tests and treatment;
  • Interact with other healthcare professionals who will assume or reassume care of the clinical problems;
  • Establish or re-establish referrals and arrange for needed community resources;
  • Assist in scheduling required follow-up with community providers and services;
  • Identify available community and health resources and communicate with those entities;
  • Provide education to the patient, family, guardian, and/or caregiver to support self-management, independent living, and activities of daily living; and
  • Assess and support treatment regimen adherence and medication management.

During the 30-day transitional period, a physician or NPP will have at least one face-to-face visit by the seventh day, but no later than the fourteenth business day post discharge.  The timing of this face-to-face visit is determined by the complexity of the patient’s condition at discharge, and the risk of significant complications associated with their clinical problems or management options.

This service allows JPMC to closely monitor patients’ progress immediately after discharge.  This also provides an opportunity to further educate, reinforce previous education, and work with patients and their families to determine the most appropriate services necessary to achieve and maintain their optimal level of wellness.