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.
Kelly Donnelly, MHA
Project Manager, Acute Care Transitions
Office of Population Health
Tel: (631) 638-1048
Steven Feldman, MD
Director, Departments of Care Management, Managed Care & Social Work Services
Stony Brook Medicine
Associate Director of Operations for Emergency Services and Internal Medicine
Tel: (631) 444-2496
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.
To begin to learn more about this program, our project documents in this section.
- Project Charter
- Project Clinical Guideline Summary
- Project Milestone Timeline
- Transition of Care Model for Inpatient & Observation Units
- Transition of Care Inpatient & Observation Units Implementation Toolkit
- SCC Transitions of Care Model (v-13).pdf
- TOC Project Flow Chart Diagram - Project 2biv
- TOC Project Flow Chart Diagram II - Project 2biv
- OBS Flow Chart Diagram - Project 2bix
- NYS DOH DSRIP Project Application Narrative - Project 2biv
- NYS DOH DSRIP Project Application Narrative - Project 2bix
- NYS DOH DSRIP Project Work Plan - Project 2biv
- NYS DOH DSRIP Project Work Plan - Project 2bix
- Project Communication Framework
- Project Consolidated Pre-Read - Project 2biv
- Project Consolidated Pre-Read - Project 2bix
Project Resources & Quick Links
This section features key external resources utilized during program development. We invite you to click the links to learn more.