Updated guidance as of 3/12/25
Please take the following Transitions of Care (TOC) steps whenever the ICMS participant is discharged from a hospital or facility and transitioning back to their unit
1. Contact the participant within 24 hours of learning about the hospitalization and schedule a TOC home visit with them. The TOC home visit should ideally occur with 72 hours after hospital discharge.
2. Prepare for this TOC home visit by finding out as much as you can about their hospital encounter. You can ask the participant if they received any discharge paperwork, call the primary care provider (PCP) to request information, or request the hospital records (if there is adequate information sharing consent on file). The ICMS Snapshot now includes information on emergency room and in-patient hospital encounters for ICMS participants.
Some of the information you might want to review includes:
- The reason for the hospitalization
- Any important discharge instructions
- Any significant changes to medications (Were the actual medications given to client, or were they asked to go pick them up?)
- Any follow-up appointments (Were these made, or was client asked to make them?)
- Any home health set-up or equipment ordered (e.g., a visiting nurse or oxygen)
By knowing beforehand what are the key follow-ups, you can focus your TOC visit on making sure these things are understood by the participant and in process.
3. Do a TOC home visit. Review the reasons for hospitalization, changes in medications, need for home support and durable medical equipment (DME), and treatment recommendations (e.g., eat less salt or do dressing changes twice a day.) Also assess for red flags. Is the participant feeling better or worse? Do they look sick?
4. Email or call the participant’s PCP with significant findings or concerns from your TOC home visit. Make sure that communication with the PCP is documented in CHAMP.
5. Complete a TOC Case Note in CHAMP. In the ‘Note Type’ drop-down list, select “PH Provider Case Note.” In the ‘Service’ drop-down list, select “ICMS TOC Visit.” Make sure that the information entered in CHAMP is consistent with the participant’s information sharing consent status (e.g., Full Sharing, Limited Sharing, Declined/Refused, Revoked).
6. Ensure that the participant has an appointment with their PCP within 2-4 weeks of discharge, and consider accompanying them to this appointment.
7. Refer high-risk participants to PH² so that the DHS-HFH and/or DMH Clinical Team can support you/participants during these high-risk transitions. High-risk participants are those with 4s or 5s on their most recent 5×5 assessment, and who have one or more recent hospitalizations.
To complete this referral, submit the PH² referral form, found here:
- If physical or medical assistance is required, email the referral form to: HFHmedicalcasemanagement@dhs.lacounty.gov
- If behavioral or psychiatric assistance is required, email the form to: PHsquared@dmh.lacounty.gov.
- If assistance for both is needed, send to both e-mail addresses.