Population Health - Transitions of Care

Transitions of Care (TOC) is an important topic for the transformation of health care. It is the movement of a patient from one care setting to another involving a set of proactive actions. Many patients leave the hospital, rehabilitation facility or long-term care setting often in a vulnerable state with little understanding of what comes next.


Learn More: Transitions of Care: Supporting Patients and Physician Partners

Additional Resources: To view all available TOC resources – including a toolkit and decision tree – you must log in to NaviNet® to access the Provider Resource Center. Next, go to EDUCATION/MANUALS, click Population Health University, select Care Management, and look for Transitions of Care.


As part of Highmark's Population Health University, we held a panel discussion in order to highlight why effective transitions in care are important and discuss collaborative efforts to support care coordination. We also discussed how improvements to patient care have a positive effect on the patient, physician experience and readmission rates.

The following panel discussion was produced in collaboration with the The American Journal of Managed Care® (AJMC®).

You can earn Continuing Medical Education (CME) credits for reviewing this module. Here's how: Earning CME Credits for TOC Module


  • Mike Samczak – Director, Value-Based Clinical Performance & Development, Population Health & Strategic Integration, Highmark Health
  • Kelsey Brenner – Population Health Pharmacy, Highmark Health
  • Amanda Mihalko – Director Social Determinants of Health, Allegheny Health Network
  • Holly D’Amico – Vice President, Utilization Management, Highmark Inc.
  • Amy Foster – Director Clinical Services High Costs, Utilization Management, Highmark Inc.
  • Melinda Mervosh – Director, Case & Disease Management National Markets, Highmark Inc.

Moderator: Julie Hobson - Population Health Performance Specialist, Highmark Health

Segment 1: Welcome and Panel Introduction

Segment 2: Effective Transitions in Care and How This Has Been Heightened During the Pandemic.

Segment 3: Examples of Good Handoffs and Coordination With Practices in Our Network.

Segment 4: How Can Providers Help Patients Maneuver Through the System?

Segment 5: How Does Highmark Help Support the Transition of Care Process Within Our Network?

Segment 6: Final Thoughts

Last updated on 6/13/2023 10:21:58 AM


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