An elderly man is using a walker in a living room.

Transitions of Care (TOC) Program

When a patient is discharged from the hospital, the care and follow-up they receive during the subsequent 30 days is absolutely critical; it can make the difference between a swift recovery and readmission. We work with our partners through our ACT One Health “Healthy at Home” program to coordinate a care plan for discharged patients, monitor their recovery and actively engage them in their health outcomes.

Your Journey from Hospital to Home

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STEP 1

Pre-discharge Visit

In the hospital, you will receive a visit from your
ACT One Health Transitional Care Coach.

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STEP 2

Follow-up Home Phone Call

24-48 hours after you leave the hospital, an ACT One

Health Care Coordinator will call you.

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STEP 3

Medical Provider Visit

You will be scheduled for a Transition of Care visit with an ACT One medical provider. This visit may be in person or virtual.

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STEP 4

Annual Wellness Visit

31-45 days after you arrive at home, you will be scheduled for an Annual Wellness Visit with an ACT One medical provider.

Successfully transitioning patients through our “Healthy at Home” program  

When a patient is discharged from one of our partner’s facilities, our key services include:

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Providing personalized assistance and providing guidance regarding medication

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Ensuring the patient is following and understanding discharge instructions

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Instructing patients to recognize “red flag” signs

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Coordinating appointments with qualified medical providers

The Advanced Care Team Advantage: 

Healthcare systems that partner with ACT One Health for transition of care services report:


  • a reduced burden on in-house resources
  • improved efficiencies & cost control
  • lower readmission rates
  • better patient outcomes
  • improved patient satisfaction & engagement
  • elevated Medicare Star ratings
Partner with us
A woman is helping an elderly man with a walker