Transitions of Care Program

About the Program

Category: Health (Best in Category)

Year: 2020

The Transitions of Care Program (TOC) supports high-risk, medically-complex Los Angeles County residents as they transition from an inpatient hospital stay to their homes and communities. We pair individuals who have recurring hospital admissions with a Community Health Worker (CHW) who supports them during this transition.We support participants for 30 days after hospital discharge, bridging the gap between services received in the hospital and resources available through primary care and community-based supports. We follow-up on hospital discharge plans and complete a comprehensive needs assessment and care plan focused on the participant’s goals. By partnering with a CHW from their community who shares their lived experience, we meet participants wherever they are and help them navigate the complex medical and social service systems that can address their short- and long-term needs.In addition to improving the health and well-being of the participants we serve, our goal is to reduce preventable hospital readmissions by addressing risk factors for future acute care utilization. Since we began taking enrollments in May 2017, we have observed an 8% reduction in Emergency Department visits and a 33% decrease in hospitalization rates during the 6 months before and after program enrollment.