Transition of Care

A successful transition of care happens when healthcare providers work closely with patients to ensure a smooth progression from one care setting to another. When patients move from our hospital to home health or another level of care, the discharge transition team at Southern California Hospital at Culver City will be there to help ease the changeover. Our goal is to promote the safe and timely passage of patients during this critical time.

Case managers from the discharge transition team will meet with patients within a day of them being admitted to the hospital. From there, case managers and other team members may provide the following transition of care services, as needed:

• Clarify discharge instructions for both patients and their families.
• Help patients understand their insurance coverage.
• Schedule a follow-up appointment with their primary care doctor or specialist.
• Coordinate their care needs through the insurance company for those on a managed healthcare plan.
• Assistance with getting their discharge medication at the hospital pharmacy.
• Help select an appropriate alternative living arrangement, such as a skilled nursing facility, assisted living facility, etc.
• Provide community resources to patients.
• Ensure that caregivers arrive from the home health agency.
• Answer any other questions about the discharge process that may arise.

The discharge transition team consists of physicians, nurses, social workers, discharge planners and case managers who have expertise in transition of care. Team members work with patients throughout their hospitalization to ensure a successful care transition.

For information about transition of care or any other related questions, please contact the case management office at (310) 836-7000.