Complex Care Management

Reducing hospital readmissions and costs through transitional care and advance care planning


Keeping our patients out of the hospital

What is Complex Care Management?

Complex Care Management, or CCM, is a collection of programs and initiatives designed for patients with serious medical needs, who are susceptible to more frequent hospitalization. The goal of CCM is to reduce hospitalizations and emergency room visits by bridging gaps in care through in-home provider and nursing visits, connecting members to specialists, identifying social determinants of care, providing medication reconciliation and medication changes as indicated as well as providing 24/7 access to care through our inhouse triage team.

In short, this program aims to improve communication and coordination for patients' care as they are discharged from hospitals to help avoid readmission.

Hospital Admission Reduction Program (HARP)

Our CCM program accomplishes its goals primarily through our Hospitalization Admission Reduction Program (HARP), consisting of Transitional Care Management (TCM) and Advanced Care Planning (ACP).

Contact us at 909-644-4965 for more CCM and TCM/HARP related Information.

Transitional Care Management
What is TCM?

Transitional Care Management (TCM) is a program that provides services for individuals who need help during transitions in care from an inpatient setting (including acute hospital, rehabilitation hospital, long-term acute care hospital or skilled nursing facility) to the patient’s home.

A Transitional Care Specialist will visit you at the hospital or at home to explain the benefits of the program. Then a home nurse visit will be set up to evaluate your needs.


The Program can help you:

  • Stay safe and stable at home to avoid unnecessary visits to the hospital
  • Set goals for your health
  • Prepare for routine visits to your primary care doctor
  • Answer questions and concerns you may have regarding your condition
  • Learn about your symptoms and how to treat them
  • Teach you about your health condition and your medications
Advanced Care Planning
What is ACP?

Our qualified health care professionals work to help you identify your needs, goals and medical treatment preferences so you have a plan in place for advanced care. Once these first steps are completed they will help you select the most appropriate Advanced Care Directive. The goal is to ensure that you select a health care agent that you trust and feel comfortable with and that you receive the treatment you want when you can no longer make those decisions for yourself.


Two important forms should be completed during this process: the Advanced Healthcare Directive and the Physician's Order for Life-Sustaining Treatment (POLST). These forms are available for download below.

Advanced Healthcare Directive

You have the right to give instructions about your own health care and to name someone else to make health care decisions for you. This form lets you do either or both of these things.

Download form
Physician's Orders for Life-Sustaining Treatment (POLST)

This is a medical order that tells emergency health care professionals what to do during a medical crisis where the patient cannot speak for him or herself.

Download form

The proven power of CCM

Our Complex Care Management program has a solid track record in improving the quality of care patients receive and in lowering their overall healthcare costs by significantly reducing hospital admissions. To properly research our program and see its efficacy, we teamed up with UCLA Biostatistics in a large CCM Study.

Healthier patients

90 days after enrollment in the CCM program, we saw some wonderful changes: emergency room utilization decreased 34.19%, number of hospital admissions decreased 62.58%, and hospital bed days decreased 62.87%.

More affordable care

The estimated cost savings attributed to the CCM model was $44,708,312. Estimated operating cost of the CCM model was $19,331,564 which gave a total estimated net savings of $25,376,748; return on investment (ROI) 2.31. The cost savings analysis and ROI demonstrated a significantly cost effective model of care.

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