Transitions of Care Clinic (TOCC)

Launched by HACKENSACK MERIDIAN HEALTH · Apr 14, 2025

Keywords

ClinConnect Summary

The Transitions of Care Clinic (TOCC) study focuses on helping patients with heart failure who are transitioning from the hospital back to their homes. This is an important time because patients often face challenges that can lead to medication mistakes, health setbacks, or even returning to the hospital. The TOCC aims to provide support for these patients by offering education, tools, and resources to manage their condition effectively at home. The program will use videos on iPads to teach patients and provide them with helpful kits that include items to monitor their health, like tracking daily weights and fluid intake.

To participate in this study, adults aged 18 to 90 who have been discharged from Ocean University Medical Center after being treated for heart failure with preserved ejection fraction (HFpEF) may be eligible. Participants will receive follow-up calls within a few days of leaving the hospital and again before a month has passed to check on their progress and ensure they have the support they need. This program is designed to improve their quality of life and reduce the chances of returning to the hospital, highlighting the importance of coordinated care during this critical transition period.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • Adults ages 18 to 90 years old discharged from Ocean University Medical Center (OUMC)
• • Inpatient admission for heart failure with preserved ejection fraction (HFpEF) exacerbation
• • Patient discharged home
• Exclusion Criteria:
• • Refuse to participate in TOCC phone calls
• • Discharged to a facility
• • Discharged with homecare services
• • Discharged on hospice services
• • Hemodialysis
• • Leave against medical advice (AMA)
• • Pregnant
• • Diagnosed with dementia
• • Without medical capacity or unable to provide own consent