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
Helping people navigate care. Helping organizations improve it.
TransitionPoint brings clinical insight, operational experience, and practical problem-solving to the moments when care gets complicated.
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.
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Individuals & families
Get clear guidance when care feels overwhelming.
Practical coaching for care transitions, benefits, services, caregiver decisions, and next steps.
Explore care coachingFor organizations
Better processes. Stronger teams. Safer transitions.
Support is tailored to your population, contracts, workflows, and operational reality. The goal is practical improvement your team can sustain.
LTC Transition Program Assessment
Evaluate existing operations, identify gaps, and clarify the barriers affecting transition volume, timeliness, and outcomes.
Program & Workflow Development
Design or strengthen referral pathways, assessments, roles, escalation points, tracking practices, and post-transition follow-up.
Complex Transition Consultation
Bring focused clinical and systems-level thinking to high-barrier cases involving housing, income, benefits, caregivers, or fragmented care.
Training & Staff Development
Practical training on LTC transitions, discharge planning, Social Security and CAPI, community-based services, and interdisciplinary practice.
Case Review & Quality Improvement
Review cases and documentation for patterns, missed opportunities, workflow drift, and improvements that support quality and accountability.
Implementation & Advisory Support
Turn recommendations into practice through structured implementation support, case consultation, coaching, and ongoing guidance.
Experience 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.
200%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. You’ll get practical guidance based on your priorities, resources, and the realities of the care system.
Book a Free Strategy CallCare 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.”
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.
L.herrera.msw@gmail.com