toctoctoc

The Transitions of Care (TOC) service functions as a critical liaison among discharging inpatient LIPs, care management teams, patients, and skilled nursing facilities. The program is designed to support timely and safe discharges, reduce unnecessary emergency department visits and hospital readmissions, and streamline overall length of stay. TOC also provides targeted patient education and strengthens collaboration between UVA Health and post-acute care partners, including skilled nursing and long-term care facilities.

Originating from a systemwide initiative to improve patient flow and care transitions, the TOC program currently supports adult inpatients across the Medical Center. Its primary objective is to build structured connections with patients transitioning to facility-based care. This includes optimizing discharge plans, ensuring medication reconciliation, supporting patient engagement, and enhancing care continuity—all of which contribute to more efficient resource utilization and improved patient outcomes.

Concerns or Complaints

For additional questions, contact:
Beverly M. Tucker
434.409.4190
BMT4Q@uvahealth.org

Ashley Balazs, COTA/LPTA

Population Health Clinical Care Coordinator

Mary Mulshine-Rosadina, BSN, RN, ACM

Population Health RN Case Manager

Michelle Decker, RRT

Population Health Clinical Care Coordinator

Suzanne Malone, BSN, RN, ACM

Population Health RN Case Manager

Ralph Watson

Population Health Specialist