CICOA 30-Day Transitional Care and Long-Term Follow Up

1. The client is referred for care management from a caregiver, hospital, nursing facility or physician’s office and transferred to the appropriate CICOA department or care manager.

  • Professionals, caregivers and clients seeking general information will be transferred to CICOA’s ADRC department to speak with an options counselor.
  • Eligible clients referred for transitional care are transferred to a care manager.

2. The care manager will contact the client as soon as possible by phone to schedule a face-to-face visit.

  • If the client is hospitalized or in a nursing facility, the care manager will meet with the client, caregiver and other professionals involved in the client’s care at their facility.
  • The care manager will assist with discharge planning, identifying community resources and identifying potential funding sources that allow for the most ideal transition back into community living.

3. The holistic assessment is then completed in the client’s home environment. The initial visit includes:

  • Completing the holistic assessment tool.
  • Coordinating with the client and his or her support group to schedule a visit to see the primary care physician.
    • If the client is already living in the community, a primary care physician visit will be scheduled if the client has not seen his or her physician within the last year.
    • If the client does not have a primary care physician, the care manager will assist with locating one.

4. Upon completion of the assessment tool, the care manager will co-develop a care plan with the client and his or her support group to address immediate concerns and establish long term goals.

5. The care manager then visits the client and his or her support group to discuss how to accomplish the identified goals.

  • The care manager does this by using a teach back method to confirm understanding and address concerns identified by the client or support group.

6. The care manager then visits the client one month after the care planning meeting.

  • During this visit the care manager will assist with identifying changes in care, secure additional resources, and update any changes to the care plan.

7. After the one month follow up meeting, the care manger will visit the client quarterly to assess for changes in care and update the care plan accordingly.

 

Please note:

  • The holistic assessment is completed by a care manager every 6 months from the client’s date of enrollment or from the date of the most recent hospitalization/facility visit, to update the client’s care plan.
  • Care managers will continue to visit on a quarterly basis unless the client has been to the Emergency Department, hospitalized or admitted to a facility. If such an event occurs the care manager will initiate the 30-day transitional care process.
  • Clients have access to their care manager by phone to answer immediate concerns, provide clarification about services, confirm community resources have been secured, and to follow up on the progress of their care plan.
  • The care management process can be adapted to meet specific agency requirements for assessment tools, care planning, data entry, etc.