Continuum of Care
Continuum of Care at Kaiser Permanente East Bay is comprised of the following service lines that care for Kaiser Permanente members in the community:
Transitional Care Case Management Program
This program is comprised of RN and SW Case Managers who provide telephonic care coordination for patients discharged home from the hospital. Our interventions include symptom and disease management, medication reconciliation, health education, and psychosocial support.
Home Health Services
The program provides medically necessary, intermittent skilled services including nursing, physical, occupational, or speech therapy for homebound members to stabilize or improve the member status at home. These services are coordinated and facilitated by case managers under a plan of care authorized by the physician.
Life Care Planning
Life Care Planning (LCP) for future health care enables patients to consider what matters most to them, so that loved ones and physicians can know and honor their wishes if they were unable to speak for themselves.
Palliative care is a multi-disciplinary medical specialty for patients and their families facing serious and advanced illness. The mission of our palliative care team is to achieve the best quality of life for our patients through relief of suffering, control of symptoms, and restoration or maintenance of functional capacity for as long a possible while remaining sensitive to personal, cultural and religious values, beliefs, and practice and providing education and support to family and caregivers.
The program offers compassionate end of life care for members with a terminal condition in the comfort of their home.
Skilled Nursing Services
The program arranges temporary transfers to a nursing or rehabilitation facility for members not ready to return home.