Care Transition Interventions are focused on coaching the member and the member’s support system during the inpatient stay and the immediate post-discharge period to ensure timely, safe, and appropriate medical care in the most efficient and cost-effective manner.

Knowledge of internal and external processes surrounding the inpatient and post-discharge stay is essential in navigating the health care continuum and addressing barriers to post-discharge success for the member.

Members can call the Transitional Care Services toll free line anytime during their inpatient stay or after their discharge to request TCS support 866-801-6294.

Providers are encouraged to refer members while inpatient or recently discharged from a hospital within the past 10 days to the Transitional Care Services program. Providers are still responsible for ECM and CS referrals/coordination as appropriate and required by DHCS.

If the member is beyond the 10 days post discharge, please refer to the Complex Case Management Program.