After you’re discharged, our care team reaches out to check on how you’re doing, answer questions, and help coordinate your follow‑up care. Based on your needs, you may receive additional support with medications, appointments, or access to community resources.

Our team includes care navigators, nurses, and community health workers who work together to support you. In some hospitals, registered nurses are available to help coordinate care before you go home and connect you to ongoing support after discharge.

This program is short term and available at no cost to eligible HMSA members.

How will I work with my care manager?

You’ll have access to a Hawaii‑based Transitions of Care team, including TOC nurses, community health workers (CHWs), and care navigators who work together to support you after your hospital stay. The team will connect with you or your caregiver by phone, virtual visit, or in person, at your home, a provider’s office, or an HMSA Center, to help ensure a safe and smooth transition from the hospital to home.

Through the TOC Program, you’ll receive:

• Help to make sure that you understand your hospital discharge instructions.
• Coordinated care with your primary care provider (PCP) or specialists. For example, your care manager will make sure you have a follow-up appointment with your PCP within one week after you’re discharged from the hospital.
• Help with understanding your medications and treatment plan.
• An action plan with steps to take in case you experience worsening symptoms related to your condition.
• Help to set and achieve health goals.
• Information about community resources to support your health and well-being.
• Discussion of advance care planning (e.g., advanced health care directive, living will, or power of attorney).

For more information about this program, call HMSA Health and Well-being Support at 1-855-329-5461, option 1.