Inpatient Transition Team

Provides coordinated discharge care planning and management for high-risk patients with complex medical, physical, and / or mental health issues.

This program works closely with geriatricians and community care programs to coordinate discharge planning for high-risk patients with complex medical and / or physical issues. Services may include:

• assesses high-risk patients, both in the hospital and in their homes
• some sites offer a follow-up clinic
• some sites offer home parenteral therapy (HPTP) and wound care services