The Guardian Health Services (GHS) Transitions of Care (TOC) Program

The Guardian Health Services (GHS) Transitions of Care (TOC) Program is designed to provide a systematic set of actions and activities directed at ensuring timely and effective transition of patients between settings (e.g., hospital to home; hospital to  post-acute facility) as individual patient conditions and care needs change. The program can be implemented by client organization administrative and clinical staff with patient data integrations through the Guardian IT platform, or through contracted use of highly trained Guardian Care Managers who can work directly with hospital discharge staff to address, prior to patient discharge, individual patient unique problems and needs, formulate a team-based and patient-centric discharge plan of care, and ensure individual patient (and informal caregiver, if available) understanding of what to expect post-discharge, how to respond to changes in symptoms, and the importance of adhering to treatment regimens and provider appointments. The key features of the GHS Transitions of Care program solution are:

  • Clinical integration and access to patient specific clinical information necessary to formulate an effective discharge plan of care (e.g., diagnoses, test and procedure results, pending tests, medication lists, rational for medication changes).
  • Timely (within 48 hours) patient coordination and follow-up of post-discharge visit(s) with outpatient providers, with a focus on ensuring appropriate medication reconciliation on-going symptom and medication management.
  • 24/7 open patient phone access for post-discharge care management services, including addressing patient experienced barriers to adhering to the established discharge plan of care.
  • Timely enlistment and integration of appropriate high risk patients into a GHS Chronic Care Management (CCM) Program (as appropriate and applicable).

The Guardian Transitions of Care Program is specifically designed to provide client organizations with an efficient and effective avenue for:

  • Reducing the rate of avoidable re-hospitalizations.
  • Reducing the rate of specific post discharge problems.
  • Reducing ER utilization.
  • Reducing utilization costs.
  • Ensuring timely patient/provider interaction and medication reconciliation post discharge
  • Enhancing HCAHP performance
  • Enhancing Patient/Caregiver Satisfaction with TOC Services
Skip to content