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