Inova Transitional Services was developed to bridge gaps in care that patients experience as they transfer across care delivery settings between illness and recovery. The service focuses on care coordination and community collaboration in order to improve health outcomes of patients at the highest risk who lack access to needed resources.
Inova's Transitional Care Management (TCM) Program focuses on traditional Medicare/ Medicaid, Innovation Health, Medicare Advantage and uninsured patients with chronic illnesses, in particular those with heart failure (HF), chronic obstructive pulmonary disease (COPD), pneumonia and diabetes.
For 30 days after discharge from the hospital or emergency room, TCM case managers monitor patients, primarily by telephone. They educate patients about their illnesses, ensure they have a follow-up appointment with their primary care physician (PCP), and confirm they have filled any needed prescriptions and are taking the correct medications.
Transitional Services Clinics
The Transitional Services clinics have locations in Alexandria, Fairfax, Herndon and Leesburg. The services offered support patients being discharged from an Inova hospital or Inova emergency room who either do not have a medical home or cannot get an appointment with their PCP within 72 hours following a hospital admission. Patients are typically followed by a hospitalist or nurse practitioner for one to three visits, while the patient and the care team work together to establish a permanent medical home for the patient or transition the patient back to their PCP. The Transitional Services clinics expanded services in 2014 to include an anticoagulation clinic to better serve our client population.
Inova Transitional Services seeks to provide services that will enhance the lives of patients so that they may better manage their healthcare and live longer, more productive lives. Patient referrals to Inova Transitional Services department programs are internal only and coordinated through Inova inpatient and outpatient providers for patients who have had an Inova hospital or Inova emergency room encounter within the last 30 days.