T.O.R.C.H. – Transitioning Onto Rehabilitation & Continuing Home
This process; T.O.R.C.H. addresses the continuum of care from the Transitioning from acute care/hospital, Onto Rehabilitation (skilled or post-acute care with an emphasis on therapy as appropriate), to Continuing Home (a lower/more independent level of care.
T.O.R.C.H. is… Transitioning Onto Rehabilitation and Continuing Home.
Key components of the program include a Transition Coach who works as a patient advocate, patient lead care planning which encourages self-directed and individualized goals, medication reconciliation, the use of teach back tools for patient and caregiver education, enhanced communication with our patient’s primary care physician, a “Discharge-to-In charge”© phase to promote successful transitions home or a lower level of care, and coordinated patient follow-up well beyond discharge.
This program and key processes have enabled us to reduce 30-day rehospitalization rate to below 16%, as well as improve our discharge to community rate above 57%, outcomes that well surpass national averages!