For patients with ongoing health concerns, the end of a hospital stay can be a time of uncertainty around how they will care for themselves moving forward. Upstate University Hospital has a resource to help patients through that uncertainty, and to help them be safe and healthy in their post-hospital lives. Upstate's Department of Transitional Care assists patients after they leave the hospital by connecting them with services and providers that are essential to the next steps in care, while engaging patients and family caregivers in the process.
This transitional care intervention begins during the hospital stay, streamlining movement within the hospital from unit to unit. Then intervention continues to the post-acute providers, including rehabilitation centers, certified home health agencies, pharmacies, Meals on Wheels, Hospice, Rescue Mission, the Salvation Army and more. The results of the intervention have been positive and Upstate has already begun to see a decrease in readmissions.