Transitions of Care (TOC) Guidance
Follow these steps whenever an ICMS participant is discharged from a hospital or facility and transitioning back to their unit. Timely outreach and a structured home visit are critical to preventing rehospitalization and supporting housing stability.
Updated Guidance for Transitions of Care
Follow these steps whenever an ICMS participant is discharged from a hospital or facility and transitioning back to their unit.
Updated guidance as of March 12, 2025. The ICMS Snapshot now includes information on emergency room and inpatient hospital encounters for ICMS participants.
Contact the Participant Within 24 Hours
Contact the participant within 24 hours of learning about the hospitalization and schedule a TOC home visit. The TOC home visit should ideally occur within 72 hours of hospital discharge.
Prepare for the TOC Home Visit
Find out as much as you can about the hospital encounter before the visit. You can:
- Ask the participant if they received any discharge paperwork
- Call the primary care provider (PCP) to request information
- Request hospital records if there is adequate information-sharing consent on file
Key information to review:
- The reason for the hospitalization
- Any important discharge instructions
- Any significant changes to medications — were the actual medications given to the participant, or were they asked to pick them up?
- Any follow-up appointments — were these scheduled, or was the participant asked to make them?
- Any home health setup or equipment ordered, such as a visiting nurse or oxygen
Conduct the TOC Home Visit
During the visit, review:
- Reasons for hospitalization
- Changes in medications
- Need for home support and durable medical equipment (DME)
- Treatment recommendations such as dietary changes or wound care
Also assess for red flags. Is the participant feeling better or worse? Do they appear unwell?
Contact the Participant’s PCP
Email or call the participant’s PCP with any significant findings or concerns from your TOC home visit. Make sure all communication with the PCP is documented in CHAMP.
Complete a TOC Case Note in CHAMP
- In the Note Type drop-down, select PH Provider Case Note
- In the Service drop-down, select ICMS TOC Visit
- Ensure information entered in CHAMP is consistent with the participant’s information-sharing consent status: Full Sharing, Limited Sharing, Declined/Refused, or Revoked
Schedule a PCP Follow-Up Appointment
Ensure the participant has an appointment with their PCP within 2 to 4 weeks of discharge. Consider accompanying them to this appointment.
Refer High-Risk Participants to PH²
Refer high-risk participants to PH² so that the DHS-HFH and/or DMH Clinical Team can support you and participants during these high-risk transitions.
High-risk participants are those with 4s or 5s on their most recent 5×5 assessment who have one or more recent hospitalizations.
To complete this referral, download and submit the PH² Referral Form, then send to the appropriate contact:
- Physical or medical assistance: HSHmedicalcasemanagement@HSH.lacounty.gov
- Behavioral or psychiatric assistance: PHsquared@dmh.lacounty.gov
- Both physical and behavioral assistance needed: Send to both email addresses above