Making sure you have everything you need to safely recover at home following a hospital stay can be stressful. The transition of care (TOC) teams work with you and your caregivers to make sure you have what you need in the first few weeks after you return home. This includes assisting with scheduling any follow-up visits, making sure you are taking the right medications and providing education about your condition.

The transition of care teams include the following services:  

Acute Care Bridge Clinic (ACBC)

The goal of our ACBC is to help bridge the transition from the hospital to your home. Our team of care navigators collaborates with specialists to provide immediate follow-up care virtually through a video visit after your discharge from the hospital. Care navigators can help manage questions regarding medications, follow-up visits and more.

Remote patient monitoring (RPM)

If you have a chronic disease, such as congestive heart failure, RPM may help you learn to manage your condition from home. If your clinician feels you will benefit from this program, they will place an order for you to receive a kit that includes tools to record your vital signs. Information is reviewed by a member of the RPM team, and if needed, they will reach out to discuss any concerns or pass along the information, to your clinician to further review. Patients usually stay on this program for about 90 days.

LVHN@Home

LVHN@Home combines home nurse visits, virtual physician visits and enhanced remote patient-monitoring to help those who may need to be monitored, but not necessarily hospitalized. As part of the program, your clinician will place an order for you to receive a kit that includes tools to record your vital signs. Information is reviewed by a member of the RPM team who coordinates care between home care and the ACBC. The ACBC will see you via video, as needed, throughout the program. Patients usually stay on the LVHN@Home program for two weeks or less.

Transition of care and care navigation

Our transition of care team members are available to help you following your discharge from the hospital. You may receive a call within two business days of your discharge to help schedule any follow-up visits you may need, reconcile your medications and review any questions you may have. If you are eligible, a transition of care team member may provide care coordination services for 30 days after you are discharged.