Safe Transitions of Care Transition planning begins upon admission and is a joint effort with the patient, his/her family, the clinician and hospital care team. Reassessment of the patient’s needs continues throughout hospitalization. Care and treatment instructions are provided to the patient upon discharge, to be followed at home or at the accepting agency. Follow-up phone calls may be made by OMC staff to the patient after discharge. Follow-up appointments for patients should be made by OMC staff prior to patient’s discharge Please see Discharge Planning and Referral Policy and Procedure for further details