Transitions of Care

It seems that summer weather is finally here. Time to break out the grills and sunscreen. Much like the shift in seasons, HVC has experienced a few changes over the last two months. As you all know we have welcomed someone new into the family as well as gave an old friend new responsibilities. We appreciate you rolling through the changes with us as we continue to provide excellent care for our members.

In the midst of all these changes HVC and HRH Care began planning the Transitions of Care Follow-Up Calls. The two lead Health Homes asked the Care Management agencies what improvements could be made to ensure we are hitting the mark when it comes to implementing transitions of care workflows.

As someone who until recently was an outsider, understanding why it is so crucial for care managers to know when members visit the emergency department is the key to understanding why care managers are needed in the first place. So many times people visit the emergency department for reasons that could have been treated at urgent care or could have been avoided if the member had the proper support system. Each CMA devoted the last few months to creating TOC Action Plans that best fit their agency culture.

Through the TOC Action Plans, Facilitator, Kristin Woodlock, and the CMAs were able to identify three key areas for improvement: Follow-up procedures, educating members on avoidable ED visits, and developing communication protocols with community providers. Each of the three components is as important as the next. The first set of calls took place May 21st and focused on the follow-up procedures. These calls allowed the CMAs to discuss what steps they have in place, what has worked and what needs to be adjusted.

The successes ranged from new employee responsibilities to restructuring workflows and changing methods of tracking. It would be unrealistic to expect no push-back when it comes to the implementation of workflow changes. The main challenges addressed were technical issues and also staff burnout. It is no secret Care Managers have a lot on their plates but continue to push through for the benefit of their members. This is why HVC finds it so important to approach components like transitions of care as a group discussion, to figure out as a team how we can help one another.

******************Note from the Writer***********************

Hello, everyone! My name is Brianna Rodriguez and I am the new Program Coordinator here at HVC. Some of you may know me but I wanted to introduce myself to those of you whom I have not had a chance to meet. I look forward to all of the work we will do together. My hope for this blog is to make it as engaging for the network as possible. I know I cannot be the only writer here at HVC, so if you ever write a piece or would like to write a piece you think the network would find interesting please drop me a line at

Leave a Reply

Your email address will not be published. Required fields are marked *