Transitions of Care - Personalized Support for Seamless Continuity of Care

 


Integra’s Transition of Care (ToC) program, one component of Integra’s comprehensive CompleteConnect offering, is also available as a standalone solution. When readmission rates are unacceptably high and quality scores are negatively affected, Integra’s 30-day post-discharge ToC program can be rapidly implemented to supplement existing efforts. 

Providing continuity of care, advocacy, coordination, and communication to ensure proper understanding and execution of post-discharge plans is essential to a member’s recovery and to clients’ success in value-based care. Integra’s ToC program provides a support structure for member transitions which reduces readmission rates. 

Our Community Health Worker model is at the core of our ToC program, providing members and their caretakers with a personal guide through the post-discharge period, performing the following services:

  • Visit members in the hospital prior to discharge by leveraging daily census or HIE feeds
  • Review the discharge plan with member and caretakers
  • Visit member in the home or the caregiver’s home post-discharge 
  • Ensure member has adequate supply of prescribed medications and understands the medication schedule
  • Schedule necessary follow-up provider appointments on a timely basis
  • Provide appointment reminders and arrange transportation if necessary 

During the 30-day transition period, a member’s Community Coordinator is available 24/7 to answer any questions and provide additional support as needed. Following the initial transition period, the Community Coordinator typically transfers the member to the client’s care or case management if necessary. 

Contact us today about implementing our Transitions of Care program for your members.