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Care Transition

Care Transition is the transfer of patients from one doctor to another or from one facility to another-- such as from a hospital to a nursing home or another care setting. The goal during care transition is to provide seamless care and prevent any loss of important medical information.

For the most successful transition, focus on these things:

  • Medication Self Management – know what medications you take and discuss any changes with your primary care physician.
  • Follow-up care with primary care physician and specialists – understanding the importance of follow-up care after discharge can prevent re-hospitalization.
  • Red Flags – know what are the important signs and symptoms of your medical condition to report to your primary care physician.
  • Personal Health Record – keep track of important medical information so you can share it with healthcare providers.


You can also get a copy of a booklet called Taking Care of Myself: A Guide for When I Leave the Hospital. The information can be used by both hospital staff and patients during the discharge process. The booklet provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers. It’s published by Agency for Healthcare Research and Quality (AHRQ). Click below.

https://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/goinghome/index.html - English (by clicking this link you will be directed away from Inter Valley's Website)

https://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/goinghome-esp/goinghomesp.html - Spanish (Al hacer clic en este enlace, se lo dirigirá fuera del sitio web de Inter Valley)

More resources available through Inter Valley Health Plan include our Care Management and Disease Management Programs. Through them, members, families, and providers have telephone access to a dedicated nurse-led care management team and a social worker. The team offers assistance with complex medical care needs and coordination, self-management education and tools, as well as help accessing community resources. 

The program helps reinforce the treatment plans developed by healthcare providers, so members can stay healthier. It also educates members on making responsible decisions about their healthcare. This kind of collaboration is called care coordination, and its goal is to help members receive the right care in the right place at the right time. Even more, Inter Valley Health Plan’s nurses and social worker serve as advocates in the healthcare system, because they anticipate and resolve problems for you. In other words, they help our members navigate the healthcare system effectively. As a member, you can request a Personal Care Advocate. 

Inter Valley Health Plan’s Care Management and Disease Management team can be reached at (909) 623-6333 x249. Call for any care management referrals or assistance with care coordination and the discharge planning process. 

This is just one more way Inter Valley Health Plan is staying true to our goal of providing high-value, person-centered healthcare. Because to us, it’s personal.


Updated 11/5/2018