The Care Transitions Program 

This program helps members who have been sent home from the hospital avoid returning to the hospital. Once home, members can be referred to HPSM’s Integrated Care Management (ICM) Team for follow-up. The ICM Team assigns each member a Care Manager who:

• Helps the member develop and follow their care plan.
• Connects the member with their primary care provider (PCP).
• Talks with the member’s family about other care needs.