The transition from hospital to home can be a vulnerable time for members from a continuity standpoint. Care Transitions is designed to support members as they transition from the hospital or care facility to the home setting or another care setting. It provides an integrated approach to support care coordination and access to appropriate follow-up care and programs.
Care Transitions helps members navigate the healthcare system. Through an assessment process, we recommend programs and services if you may be at early risk for health concerns. We also assist members in coordinating support services related to recovery and ongoing care.
Care Coordinators are Registered Nurses or licensed healthcare professionals. They will help facilitate healthcare needs and encourage health improvement.
Care Coordinators are available to:
- Offer education and pre-planning activities prior to undergoing surgery or procedures
- Work with the inpatient facilities to assist with safe discharge planning for serious illness or injury that may require intensive follow up care
- Help understand what coverage is in place for the planned treatment
- Provide education and support following discharge after a health event that may require coordination of homecare - for example, intravenous (IV) care, rehabilitation to other related services. It also includes providing assistance to members and their families to better understand prescribed medications and information to support treatment plan adherence.
If the member's recovery becomes longer term, the member is transferred to our complex case management team to coordinate further recovery and health improvement at a higher intensity level. Care Coordinators will continue to make follow up calls to members until members feel that they no longer need the support.