Transitional Care Services (TCS)

Medi-Cal members who experience a hospital or facility admission are eligible for the Transitional Care Services (TCS) Program. Members will receive coordination and support to ensure all needed resources and services are received at home. Support includes, but is not limited to, scheduling follow up office visits, coordinating transportation, and connecting the member to caregiver assistance. 

Eligibility

All Medi-Cal members are eligible for Transitional Care Services.

Team Structure

The Care Management Department works as an interdisciplinary care team to support our members. 

The Care Management team assigns each eligible member to a Care Manager. The Care Manager serves as the member's primary point of contact and works with all their providers – such as doctors, specialists, pharmacists, social 
services providers, and others—to ensure all disciplines align in member’s care.

The Care Management is an interdisciplinary care team consists of the following roles and/or functions, at minimum:

  • Care Manager — a Registered Nurse or Licensed Clinical Social Worker
     
  • Community Health Worker — a paraprofessional who collaborates with Care Managers to provide additional support to the member out in the field
     
  • Care Coordinators – supports Care Managers with administrative tasks and member engagement  
     
  • Care Management Medical Director – provides medical oversight and consultation for members in our Care Management program

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