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The Effectiveness of the Transition of Care (TOC) Program in Lowering Readmission Incidences.

A quantitative study was performed by managers at my workplace to demonstrate the effectiveness of the Transition of Care (TOC) program in lowering readmission incidence. The TOC program aims to decrease the readmission of high-risk clients after being discharged from the hospital.

One program intervention is TOC nurse case managers visiting clients at their house for a better follow up of the discharge process. The TOC nurses complete proper medication reconciliation, check with clients the orders received from the hospital and help them to coordinate services such as follow-up appointments, transportation, outpatient therapies, durable medical equipment, and home health care services.

As reported by Dossa, Bokhour, and Hoenig (2012), the absence of continuity of care after discharge is often due to miscommunication between hospital providers, home health care agencies, and outpatient clinics.

They also mentioned that patients often do not understand whom they need to contact once at home. The data for the study was collected from the admission reports and the sample were all the clients belonging to the Special Needs Plan (SNP) being readmitted to the hospital in the year 2015.

A retrospective correlational design was used to study the relationship between readmission in the hospital within 30 days and whether or not the client received the TOC program services.

The results of the study showed an association between TOC nurses follow up services and the decrease in the incidence of hospital readmissions within 30 days. Thus the study results supported the manager’s proposal to the board of directors to increase TOC nurse case manager positions.

One of the study strengths is the type of design chosen because correlational designs are used when the researchers are studying the relationship between variables (Polit & Beck, 2017).

One limitation of the study threatening its internal validity is that it did not consider an important variable, the reason for admission. It is well-known that some illnesses, such as chronic obstructive pulmonary disease (COPD) as per Cox, Macleod, Sim, Jones, and Trueman (2017), have major incidence in hospital readmission where the TOC program might have some if no effect at all.

1 thought on “The Effectiveness of the Transition of Care (TOC) Program in Lowering Readmission Incidences.

Adam April 1, 2019 at 2:53 pm

I love this one. It introduces Transition of Care (TOC) as a program aimed at discovering,
evaluating and providing the solutions that could help reduce the readmission rates of patients
after being discharged from the hospital.
Citing the study outcomes, it is evident that the design method applied was an accurate approach to collect and analyze the available data for patients belonging to the Special Needs Plan (SNP) being readmitted to the hospital in the year 2015 (Dexter, etal, 2014). Effectively, retrospective correlational design was used to determine the most effective sequence and timing of nursing Transition of Care interventions that would provide the best outcomes for the patients (Jonsen etal, 2015).
The author quotes open communication channels as an important factor among all the relevant stakeholders to ensure there is decrease in readmission rates. However, it is well indicated that the study was limited in validity as it did not consider the reason for admission, which stands out as a key variable in the study (Polit & Beck, 2017, p. 44).

I am in agreement with the author of this post in that if at all TOC programs could be well executed; they improve the quality of services the patients receive both directly and indirectly. With that, the hospital should develop TOC program services to enhance the continuity of care after discharge.


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