Transition of Care Program for Inpatient & Observation Units (TOC)

Project 2biv image

Transition of Care Program for Inpatient & Observation Units (TOC)

Project 2biv - Care transitions intervention model to reduce 30-day readmissions of chronic health conditions
Project 2bix - Implementation of observational programs in hospitals

Project Objective Statement

To provide a 30-day supported transition period after a hospitalization to ensure discharge directions are understood and implemented by the patients at high risk of readmission, particularly patients with cardiac, renal, diabetes, respiratory and/or behavioral health disorders.

To establish appropriately sized observation units (either dedicated beds or scattered beds) in all hospitals in the county to reduce short stay admissions, thereby minimizing Potentially Preventable Readmissions.

Project Management

Sofia Gondal, MA
Project Manager
Office of Population Health
Tel: (631) 638-1349

Project Leadership

Steven Feldman, MD
Director, Departments of Care Management, Managed Care & Social Work Services
Stony Brook Medicine 
Tel: 631-444-7471

Eric Niegelberg
Associate Director of Operations for Emergency Services and Internal Medicine
Tel: (631) 444-2496

Project Committee Membership

Project Workgroup Charge
A composition of subject matter experts engaged to support the development, execution and monitoring of project milestones.

Project Committee Charge
A composition of key internal and external project stakeholders, including representation from key community and public service and governmental agencies engaged to support the conclusions, deliverables and monitor system impacts of the DSRIP Program.

Project Workgroup and Committee Membership Directory

Project Documents

To learn more about this program, review our project documents in this section.

Project Resources & Quick Links

This section features key external resources utilized during program development. We invite you to click the links to learn more.

Learning Symposium presentation by Amy Boutwell, MD, MPP, on December 14, 2015 to the SCC Transition of Care Workgroup entitled Reducing Avoidable Hospital Utilization, Best Practices and Promising Strategies for Medicaid Patients

Hospital Guide to Reducing Medicaid Readmissions prepared for the Agency for Healthcare Research & Quality by Amy Boutwell, MD, MPP, Collaborative Healthcare Strategies, Inc. August 2014.

STAAR Issue Brief: Reducing Barriers to Care Across the Continuum – Measuring Rehospitalizations at the State Level, by Amy Boutwell, MD, MPP, and Stephen F. Jencks, MD, MPH

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