Whole Person Care - Los Angeles (WPC-LA)

Medically High-risk

The Transitions of Care (TOC) program targets a medically high-risk subset of patients with recurring medical hospital admissions to provide comprehensive services to eligible participants prior to discharge and for 30 days post discharge. The program uses a hospital-to-home care transition approach to support patients as they leave the hospital, facilitate engagement with their primary care team, and create linkages to community based organizations to support the patients’ social service needs.

Inclusion Criteria:

  • Currently hospitalized and being discharged from LAC+USC Medical Center, Harbor UCLA Medical Center, Olive View UCLA Medical Center, or White Memorial Hospital; and
  • Not going to a skilled nursing facility at time of discharge; and
  • 3+ inpatient admissions (or emergency department observational stays) in the past 12 months; or
  • 2+ inpatient admissions (or emergency department observational stays) in the past 12 months with any of the following:
    • 4+ emergency department visits in the past 6 months;
    • Justice-involvement within the past 3 months;
    • Homelessness and not willing or able to go to Recuperative Care;
    • Serious mental illness with functional impairment;
    • Active problem with alcohol or drugs with functional impairment;
    • Initiation of insulin or anticoagulation during this admission; or
    • Taking greater than 6 medications daily.

Services Provided:

  • The Community Health Worker (CHW) performs an assessment in partnership with the discharge team to determine patient’s high-priority needs and develop a care plan that addresses the patient’s needs to prevent future readmissions;
  • Home visit within 72 hours of discharge to assist the patient with medication review, help fill needed prescriptions, schedule future appointments to primary care and specialty providers, arrange transportation as necessary, and address social service needs through referrals and linkages to social service organizations; and
  • Accompany the patient to their follow up primary care visit.

Length of Stay:
The average length of stay for the TOC program is 1 month.