Transitional Care
Helping you maintain continuity of care for your HUSKY Health patients after they leave the Emergency Department (ED) or inpatient settings.
Patients who have a follow-up appointment within seven days of a hospital discharge are less likely to have non-emergent ED visits and avoidable hospital readmissions. HUSKY Health offers Transitional Care Management services to assist members with arranging post-hospital care appointments and developing self-management skills. Transitional Care nurses reach out to complex or high-risk members to discuss post-discharge instructions and to assist you with collecting accurate post-discharge information.
Contact Us
To contact Transitional Care, call 1.800.859.9889 extension 2011.
The Transitional Care Team
The Transitional Care team consists of Inpatient Discharge Care Managers (IDCMs), Emergency Discharge Care Managers (EDCMs), and Transitional Care Coordinators who collaborate with members, caregivers, Intensive Care Management (ICM), interdisciplinary medical and behavioral healthcare teams, and other community resources.
Inpatient Discharge Care Managers
IDCMs work on-site at many of the hospitals throughout the state. They talk with members in person or over the phone while the member is at the hospital to identify barriers to care and discuss the reason for hospitalization.
In addition to working with members in the hospital, IDCMs provide hospital staff insight into specific barriers to care. Together, IDCMs and hospital staff develop a strong discharge plan for members with chronic conditions and complex medical and/or psychosocial needs. These members are then offered participation in the ICM program.
Emergency Discharge Care Managers
EDCMs identify members with chronic conditions and multiple ED visits. EDCM staff work with members to reinforce discharge instructions, address gaps in care, and help arrange follow-up appointments with providers. These members may also receive referrals to the ICM program. EDCMs educate members on the importance of having a Primary Care Provider (PCP) and appropriate use of the ED.
Transitional Care Coordinators
Transitional Care Coordinators work with members and their PCPs to arrange post-discharge follow-up appointments and provide PCPs with important post-discharge information. Additionally, they reinforce discharge instructions and address any barriers to member participation in recommended care.
How Transitional Care Coordination Works
- CHNCT receives notification of members discharged from the hospital on the previous day and instant notification of HUSKY Health members who go to the ED.
- Within 48 hours of notification, a Transitional Care nurse contacts the member to conduct telephonic assessments, perform medication reconciliation, review post-discharge instructions, and assist with scheduling a follow-up appointment. The nurse will also confirm with the member that services needed post-discharge are in place or assist with arrangement of those services, if needed.
- Referrals to ICM or other programs are made if the member needs additional services.
- Medication reconciliation letters are sent to the member’s PCP. This letter includes a summary of member self-reported medications upon discharge and any identified member education needs.
Secure emails
We’ve begun using new software for our secure emails.
During your first time sending or receiving an email with this system you’ll need to create an account with a new password. You'll use this information to log in each time you want to send a secure email. You'll also use it to log in when you receive a secure email from HUSKY Health. When creating your new account, you’ll receive an email from Proofpoint. Enter the code from the email in the field provided to complete your registration.
When sending your email, address it to provider@chnct.org for questions about reports, prior authorizations, the PCMH program, etc.
Address your email to websupport@chnct.org for help related to the provider portal, such as issues with resetting your password or accessing your account.
This portion of the HUSKY Health website is managed by Community Health Network of Connecticut, Inc.®, the State of Connecticut’s Medical Administrative Services Organization (ASO) for the HUSKY Health program. For the general HUSKY Health website gateway, please visit portal.ct.gov/husky. HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services (DSS).
