Ocean Healthcare Network spans a spectrum of different levels and venues of post-acute care, which provides the distinct advantage of a seamless care coordination within a continuum of care. Ocean Healthcare Network facilities and service lines collaborate efforts with caregivers of other member facilities who are already familiar with each patient’s history and specific care needs. Thus, if a client is receiving home health care or is an Adult Day Health setting and needs care on a sub-acute level, they can transfer temporarily to a Skilled Nursing Facility that suits their specific location and needs.

This inter-facility collaborative approach is perhaps best illustrated in Ocean Healthcare Network’s Transitional Care Coordination Program, a signature program that has made a significant impact in readmission reduction and improved outcomes.
Each year, thousands of patients in New Jersey are discharged from skilled nursing facilities to a home setting. Statistically, nearly 18% of these patients will be readmitted to a hospital within 30 days of their hospital discharge. This alarming trend is indicative of gaps in post-transition care, and it undermines the most basic goals of healthcare reform.

Ocean Healthcare Network members work as a team, providing care options such as Home Health Care, Home-Based skilled Nursing, Adult Day Health Services, Assisted Living Communities, and Hospice Care, so that discharged patients can receive the level of care they need, provided by caregivers who work in tandem with caregivers from the discharging facility who are familiar with the patient’s history and specific care needs.


Beyond the coordination of levels of care, the Transitional Care Coordination Program takes hospital readmission prevention to the next level by identifying specific causative factors and effectively addressing them head-on.Most incidents of preventable post-discharge complications fall into one of these categories:

  • Medication complications
  • Insufficient home health care
  • Inadequate durable medical equipment
  • Lack of follow-up physician/medical care

The Transitional Care Coordination effectively addresses these gaps with clear instruction and guidance at the time of discharge as well as extensive follow-up after the patient is at home. This ensures that each patient’s medications, home environment/care, equipment, and medical oversight are thoroughly addressed.