Transitions of Care - Personalized Support for Seamless Continuity of Care


Designed to help payers and providers manage quality performance and costs associated with avoidable readmissions, Integra’s Transitions of Care (ToC) program, one component of Integra’s comprehensive  CompleteConnect  offering, is also available as a standalone solution. The program provides members with an effective support structure for successful transition from the hospital, reducing barriers to proper follow-up care and lowering the likelihood of avoidable readmissions.  Integra field personnel engage members hospitalized for medical or behavioral health conditions during the crucial 30-day period post discharge, ensuring adherence to discharge plans, provider follow-up and prescribed medications.

Our ToC staff become proactive member advocates, making sure they understand and comply with post-discharge plans and timely scheduling and completion of follow-up appointments.  We serve as a key point of coordination to ensure effective continuity of care, coordination of needed medical, behavioral, and social services, and clear communication among members, their families, and providers. These are essential to the member’s successful transition and to minimizing the risk of an avoidable readmission.

Our Community Health Worker model is at the core of our ToC program, equipping members, their families and their caregivers with a personal guide to successfully navigate the critical 30-day post-discharge period.  Members receive the following services under ToC:

  • Personal engagement in the hospital prior to discharge by our ToC staff
  • Review of the discharge plan with member, the family and caregivers
  • Post-discharge follow-up visit in the member’s residence
  • Support in maintaining adequate supplies of all prescribed medications and understanding the importance of following the prescribed medication regimen
  • Assistance in scheduling and completing timely follow-up appointments with providers
  • Timely appointment reminders and assistance in arranging needed transportation to ensure appointment completion

During the 30-day post-discharge period, an assigned Community Coordinator is available to the member 24/7 to answer any questions and provide additional support as needed. Following this period, the Community Coordinator will ensure a smooth hand-off and coordination with the client’s care/case management staff.

Integra’s Transitions of Care program can be rapidly implemented to supplement and integrate with existing efforts to lower the number/rate of avoidable readmissions.  Contact us today about implementing the ToC program for your members.