Transitional Care Management Services

Welcome home. For seniors returning home from a hospital stay, our Transitional Care Management Services coordinate healthcare and rehabilitation services free of charge for Medicare beneficiaries. The goal is to improve long-term outcomes for seniors after hospitalization for illness, surgeries, or setbacks, and reduce the number of hospital readmissions. Area hospital partners include Mission Community Hospital, Providence Tarzana Medical Center, and Valley Presbyterian Hospital.

Patients enrolled in Transitional Care Management Services have a coach who meets with them at their hospital bedside, explains the program, and schedules a home visit 24-48 hours after discharge. The Transitional Care Management Services coach will:

  • Help patients become proactive participants in their medical care
  • Coordinate and schedule all follow-up physician or therapy appointments
  • Identify “red flag” symptoms, which may suggest a worsening condition, and develop a plan to respond
  • Create a list of all medications for review by patients’ pharmacists and physicians

For more information about Transitional Care Management Services, please contact Florence McNeill, Clinic Administrator for the Jewish Home, at 818.774.3333, or Florence.McNeill@jha.org.

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