Common use of Transition of Care Program Clause in Contracts

Transition of Care Program. This program addresses the needs of members who have been discharged from an acute care facility. Through the use of an automated outbound calling system, an initial screening is completed on all Members with an acute hospital stay resulting in discharge to their home. We address changes to medications, follow-up lab and imaging appointments, and physician follow-up appointments to ensure smooth transitions to home and outpatient care and minimize the potential for readmission. Depending on the member’s answers to the screening questions, which will identify potential areas of concern, members are referred on to the DOC Program for additional assessment and follow up by the DOC nurse.