Mercy Transitions of Care (MTOC) Team Offer Smooth Process from Hospital to Home

Mercy Transitions of Care (MTOC) Team Offer Smooth Transition Home from the Hospital

Taking the Guesswork Out of Post-Acute Care

MTOC Team: Julie Olechnowicz, NP, Sara Kirchhoff, LMSW and Grace LeBlanc, PA

Leaving the hospital after an acute medical stay can be a daunting experience for a patient. Remembering dosages for medication, caring for post-surgery wounds, or even knowing who to call with questions can be overwhelming during a discharge. The Mercy Health Specialists in Hospital Medicine (SHM) group, along with the Mercy Health Visiting Nurse Services (VNS) have partnered to close the gap between hospital and home: Mercy Transitions of Care, or more often referred to as MTOC.

The goal of MTOC is to provide a smooth transition from a patient’s hospital stay back to their primary care physician. With expertise in hospital medicine, internal medicine, geriatric medicine and social work, MTOC providers help manage patients discharge and medical needs within Mercy Health and throughout the community.

“A primary value of SHM is stewardship,” said Rolf Hissom, MD, Medical Director for SHM. “We see the development of MTOC as a means of honoring this value by improving the likelihood that patients can be independent, using their time as they see fit – rather than being sequestered in the hospital or nursing home. We do this by providing services and resources to the patient in their home, decreasing their likelihood of returning to the hospital or nursing home – thus, stewarding the patient’s time, health and finances.”

MTOC works in conjunction with hospital internists, nursing, case managers and care managers, homecare, primary care physicians, specialists, and therapists, to ensure patients are maintaining and improving their health once they leave acute and sub-acute care. This supportive program provides patients with a visiting nurse practitioner and physician assistant as well as a case manager that travels directly to their homes within 48 hours of discharge from the hospital. Through this unique combination of nursing and social work resources, patients receive a follow-up on their health status, as well as confirming they have appropriate support services and to supplement their health care and social needs.

“It is timely comprehensive follow up care that is inclusive of both medical and social assessments. This work results in patients having a better understanding of their medical diagnoses, medication regimen, and support in connecting to resources to help patients maintain improved healthfulness,” said Sara Kirchhoff, LMSW and MTOC team member.

MTOC is available to address patients concerns 24 hours a day, seven days a week, to patients who are within a 30-mile radius of our Mercy Health Muskegon facilities. With the goal of continuing Mercy Health’s mission of transforming and improving the health of our communities, MTOC’s personal services are billed similar to that of a physician specialist office visit. This ensures that patients do not feel excess financial burdens as a result of the MTOC efforts.

The success of the MTOC program thus far is resounding. While Mercy Health’s readmission rates are already low, MTOC has played a key role in decreasing them significantly.  Additionally, the program has been successful in helping patients return home confidently.  As pointed out by MTOC Lead and Nurse Practitioner Julie Olechnowicz, “This has really proven to be a more valuable service to our community members than I ever could have imagined when I first signed up to be a part of it. We have had so much success in such a short amount of time, that I am excited to see how much more we can do in the future.”




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