Senior Health Services

The Senior Health Services Transition of Care (SHS TOC) Clinic is for patients who need timely followup care after a hospital stay. Our staff is uniquely trained to provide you the care you need after you are discharged from the hospital. Our top priority to is help every patient recover and avoid a hospital readmission.

The SHS TOC Clinic is not a replacement for your regularly scheduled visits with your Primary Care Provider but works closely with your Primary Care Provider as a part of the Sentara Medical Group Patient Centered Medical Neighborhood. It is important that you continue to see your primary care provider, as well.

What to Expect at and After Your Hospital Discharge

When it is time for you to leave the hospital, your care team will provide you with discharge instructions, a list of medications, and schedule any follow-up appointments. One of those appointments will be the SHS TOC Clinic.

Within 48 hours of discharge, a SMG Nurse Integrated Care Manager (ICM), will contact to you to check in on you and help answer any questions you may have.

What to Expect at Your SHS TOC Clinic Follow-Up Appointment

You will have an appointment with the physician who cared for you in the hospital or a provider on their team. Together, you’ll review your medications and education materials. You will also talk about your health since you were discharged from the hospital.

Senior Health Services

Our Senior Health Services team is comprised of advanced practice providers (APPs) - nurse practitioners and physician assistants - who provide primary care services in the home to patients with Medicare insurance. Our team is dedicated to providing preventative care, chronic disease management, and acute care needs to patients with difficulties leaving the home, including mobility impairment, chronic disease burden, or transportation barriers. The APPs work independently or in partnership with a Sentara Medical Group primary care provider to care for their unique population of patients across Hampton Roads. Additionally, the Senior Health Services team includes a dedicated Licensed Clinical Social Worker, Community Health Worker, and Integrated Care Manager, in addition to clinical support staff, who provide each patient individualized attention to help them meet their particular needs. The goals of the team are to improve health outcomes to our most vulnerable population, reduce hospital admissions and ER visits, and promote continuity of care across the spectrum. Any homebound patients in the state of Virginia who reside within 30 miles of Sentara Leigh Hospital, Sentara Obici Hospital, or Sentara Careplex Hospital are eligible to receive our services.