01
Healthcare organizations
Build transition programs that work in real life.
For health plans, facilities, ECM providers, Community Supports providers, and community-based organizations.
Explore organizational servicesLong-term care transition consulting & care navigation
Clearer care decisions. Stronger transition systems.
TransitionPoint helps individuals and families make sense of complex care decisions while helping healthcare organizations build safer, more effective transition programs.
Bilingual MSW15+ years of experiencePerson-centered guidance
The central question
What is standing between this person and the least restrictive setting where they can safely thrive?
Two ways to work together
Choose the path that fits your needs.
02
Individuals & families
Get clear guidance when care feels overwhelming.
Practical coaching for care transitions, benefits, services, caregiver decisions, and next steps.
Explore care coachingNot sure where to start?
Connect directly to discuss the best path for you.
For organizations
Turn transition barriers into measurable, sustainable improvement.
TransitionPoint helps teams identify why transitions stall, close operational gaps, and build clearer processes that support safer transitions, stronger accountability, and better use of resources.
Fewer stalled transitions
Clarify roles, barriers, escalation points, and next steps so appropriate transitions keep moving.
More confident teams
Give staff practical workflows, training, and clinical guidance they can apply to complex situations.
Stronger accountability
Use consistent tracking, case review, and follow-up to reveal gaps and support measurable improvement.
LTC Transition Program Assessment
Find the operational and clinical barriers affecting transition volume, timeliness, and outcomes, then establish clear priorities for improvement.
Program & Workflow Development
Create practical referral pathways, assessments, roles, escalation points, tracking practices, and follow-up that teams can use consistently.
Complex Transition Consultation
Move high-barrier cases forward by connecting clinical needs with housing, income, benefits, caregivers, and community-based care.
Training & Staff Development
Build staff confidence and consistency through practical training on transitions, discharge planning, benefits, community services, and interdisciplinary practice.
Case Review & Quality Improvement
Turn case and documentation patterns into actionable improvements that reduce missed opportunities and strengthen quality and accountability.
Implementation & Advisory Support
Carry recommendations into daily practice through structured implementation, consultation, coaching, and ongoing problem-solving.
Let’s identify what is getting in the way and what your team can do next.
Book a Free Strategy CallExperience measured in outcomes
Strategy grounded in frontline practice.
Leiloni’s work spans managed care, long-term care, home health, hospice, and complex case management. She understands both the person at the center of the transition and the systems responsible for making it possible.
Discuss Your Organization’s Goals200%increase in successful long-term care transitions
84%reduction in inpatient readmissions among transitioned members
$3M+in identified savings while supporting independence and outcomes
For individuals & families
You don’t have to figure out the care system alone.
Care coaching turns a complicated situation into clear, manageable next steps based on your priorities, resources, and the realities of the care system.
Does any of this feel familiar?
- A family member is in a hospital, skilled nursing facility, or long-term care setting, and you’re unsure what comes next.
- Have you received a Notice of Last Covered Day (LCD) or a Medicare Notice of Non-Coverage (NOMNC) from the health facility?
- You’re trying to compare care options, benefits, or community services without knowing which questions to ask.
- Care options after leaving a facility feel expensive, and you’re unsure how to coordinate your loved one’s benefits to help reduce out-of-pocket costs.
- Paperwork, conflicting information, or caregiver responsibilities are making an already stressful decision feel overwhelming.
Care Transition Planning
Prepare for a safe move from a hospital, skilled nursing facility, or long-term care setting into the community.
Benefits & Resource Navigation
Understand possible programs, benefits, and community supports, and organize the steps needed to pursue them.
Long-Term Care Navigation
Think through care options, questions to ask, and how different services may fit together.
Caregiver Guidance
Create a clearer plan for appointments, paperwork, communication, care responsibilities, and changing needs.
Meet the founder
Leiloni Herrera, MSW
Long-Term Care Transition Consultant & Care Coach
Leiloni is a bilingual social worker with more than 15 years of experience helping older adults, adults with disabilities, caregivers, and healthcare organizations navigate complex care.
Her work combines psychosocial assessment, interdisciplinary care coordination, program development, regulatory knowledge, staff training, and practical resource navigation. She has developed transition programs, strengthened operational workflows, advised teams on complex cases, and helped people move toward safer, more independent settings.
“A discharge is an event. A transition is a process.”Talk with Leiloni
Free 30-minute strategy call
Let’s talk through what you’re trying to solve.
In this complimentary 30-minute call, we’ll discuss your current challenge, identify the most important priorities, and determine the best next step. This call is available to organizations, individuals, and families.
lherrera@transitionpointcs.comBook your free strategy call
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