Integrated Care Transitions Program

The Integrated Care Transitions Program at El Camino Hospital assures patients have a smooth transition between care settings.

When you or a loved one is discharged from El Camino Hospital, our integrated care team is available to offer information, resources and support for patients, family members and caregivers. The Integrated Care Transitions Program helps provide a seamless continuum of care from the hospital to recovery at home or a skilled nursing facility.

Integrated care staff will provide you with a care plan, guidance and follow up to ensure you recover from your hospital visit — they’ll help you transition from an environment of hands-on care to taking charge of your care at home. They can help you anticipate and plan for your needs outside the hospital, including providing information about homecare services or equipment, or skilled nursing, rehabilitation and other care facilities.

When you have complex health needs, our integrated care team is available to provide a high level of assistance to assure you have the care and resources you need.

Personalized Service to Ease the Transition

If you require transition assistance, your hospital care team will notify integrative care staff, who will offer personalized guidance and support. The program offers a wide range of services, depending on your specific needs, and may include:

  • A free home visit from the outpatient case manager within the first few days of leaving the hospital.
  • Coordination and communication with your primary care doctor and specialists to assure seamless care among caregivers.
  • Personal assistance from a pharmacist to go over your medications and answer any medication-related questions.
  • Phone calls from the integrated care staff to discuss your well-being, answer questions, review medications and set up follow-up visits.
  • Free eldercare consultation services, including assistance with finding care and resources that fit your budget. We offer a wide range of services and resources to assist older adults.
  • If you’re transitioning to a skilled nursing facility, a nurse from El Camino Hospital will talk to a nurse at the facility to provide an update on your condition when you’re discharged from the hospital.
  • Assistance with finding available services within El Camino Hospital and the surrounding community — including all the services available through our Health Library & Resource Center and a full range of community health services such as an in-home emergency response system and more.

Connecting You with Care

Our integrated care team provides you with information and assistance to assure you’re well prepared for the next stage in your care. Our team includes specially trained professionals, including:

  • An outpatient case manager and a transitions coordinator.
  • Specialized nurses, including an acute coronary syndrome clinical nurse specialist, a cardiothoracic surgery nurse navigator and a heart failure clinical nurse specialist.
  • A geriatric nurse practitioner.
  • A pharmacist and pharmacy technicians.
  • A geriatric social worker.

To learn more about our services, call 650-988-7633.