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 7 days of a hospital discharge are less likely to have non-emergent ED visits and avoidable hospital readmissions. HUSKY Health offers Transitional Care to assist members with contacting their providers to set up post-hospital care appointments and develop self-management skills. Transitional Care nurses outreach to members to discuss post-discharge instructions and to assist you with collecting accurate post-discharge information. 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, Intensive Care Management (ICM), caregivers, interdisciplinary medical and behavioral healthcare teams, and other community resources.
Inpatient Discharge Care Managers
IDCMs work on-site at many large and mid-size 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 collaborate with hospital staff providing insight into specific barriers to care. Together, IDCMs and hospital staff develop a strong discharge plan for members with chronic diseases and complex medical and/or psychosocial needs. When necessary, these members may receive referrals to the ICM program.
Emergency Discharge Care Managers
EDCMs identify members with chronic diseases and multiple ED visits. EDCM staff work with members to establish a plan of care, identify gaps in care, and schedule 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 schedule post discharge follow-up appointments and provide PCPs with important post-discharge information.
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.
Utilization Reports
To help you identify patients in need of care, HUSKY Health provides reports on members attributed to your practice through our secure provider portal.
Admission and Discharge reports provide information on members who have had recent hospital admissions or discharges. ED Utilization reports provide information on members who have had recent ED visits. PCPs can use these reports to schedule post discharge/continuation of treatment appointments. To access these reports, click here.
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 for the HUSKY Health Program. For the general HUSKY website gateway, please visit www.ct.gov/husky. HUSKY Health includes Medicaid and the Children’s Health Insurance Program, and is administered by the Connecticut Department of Social Services.
