Outpatient Transitions Collaborative (OTC)

Reducing hospital readmissions is a strategic priority for UNC Health Care. Hospitalized patients are vulnerable to adverse events in the period immediately following discharge, and need immediate access to a trusted clinician who can coordinate care, answer questions, provide advice, and help ensure that their clinical condition remains stable. Aligned with the UNC Transitions Leadership Initiative, the Outpatient Transitions Collaborative (OTC) was formed in September 2014 to enhance complete care across the UNC Health Care continuum.

The OTC works closely with the Inpatient Transitions team to design team-based care experiences for improved patient outcomes, such as:

  • Enhanced discharge instructions
  • Timely and coordinated follow-up communication and hand-offs
  • Prompt scheduled visits with clinic providers
  • Structured visits that support medication reconciliation and adherence.

Primary and specialty care representatives from UNC practices have joined together in the Outpatient Transitions Collaborative to facilitate shared learning and accountability for readmissions prevention, including this year’s performance improvement efforts around timely access to follow-up care after discharge. Working together with empathy and expertise, we will improve care transitions to achieve organizational improvement targets, spread effective strategies throughout the system, and meet the needs of our patient population.

If you have questions about OTC, contact the program manager, Eileen Ciesco.