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Transitional Care Management
Transitional Care Management (TCM) is a critical service designed to ensure that patients, especially older adults, experience a safe and seamless shift from one healthcare setting to another, such as from a hospital to their home or a rehabilitation facility. This period is often high-risk, as poor coordination and lack of follow-up can lead to complications, medication errors, and hospital readmissions. TCM bridges that gap by providing structured support during this vulnerable phase.
Service Overview
Transitional Care Management focuses on the first 30 days after discharge from an inpatient hospital stay, skilled nursing facility, or similar setting. During this time, patients are especially susceptible to setbacks due to incomplete understanding of discharge instructions, poor medication adherence, or insufficient follow-up care. TCM services address these challenges head-on by coordinating care across providers, ensuring timely follow-up, and empowering patients to manage their health confidently at home.
The service typically includes an initial outreach to the patient within 2 business days of discharge, a face-to-face visit within 7 or 14 days (depending on complexity), and ongoing communication to support recovery. This structured process is led by a care team that may include physicians, nurse practitioners, case managers, and clinical pharmacists, all working together to guide the patient through their post-acute recovery.
For Patients
For seniors, the transition from hospital to home can be overwhelming, filled with new instructions, medications, and uncertainty. Transitional Care Management provides structured support that helps reduce this confusion and ensures patients feel cared for during a vulnerable time. Patients benefit from timely follow-up care that addresses emerging health concerns, along with clarification of discharge instructions and personalized guidance on their treatment plans. Medication reconciliation ensures they are taking the correct prescriptions safely, while regular communication reinforces their understanding and compliance. The result is a smoother recovery process, fewer complications, and reduced likelihood of hospital readmission. Patients feel more confident in managing their health and more supported in their recovery journey.
For Providers
For healthcare providers, Transitional Care Management delivers a practical and impactful way to strengthen care continuity and reduce readmissions. By proactively identifying high-risk patients and intervening early, providers can ensure that post-discharge plans are implemented as intended. This improves both short- and long-term outcomes and increases patient satisfaction. TCM also supports compliance with quality programs and enhances reimbursement under Medicare and value-based contracts. Providers benefit from stronger patient relationships, fewer avoidable readmissions, and improved clinical and financial performance, all while delivering care that truly meets the needs of their most vulnerable patients.
TCM demonstrates a provider’s commitment to holistic, patient-centered care while supporting quality metrics that matter in today’s healthcare environment.
How It Works
Discharge Alert & First Contact
The TCM process begins the moment a patient is discharged. Our team receives discharge alerts through real-time data feeds or direct communication with hospitals. Within 48 hours, a team member contacts the patient to check in, assess symptoms, ensure medication understanding, and schedule a face-to-face clinical visit within the required timeframe.
Post-Discharge Evaluation
During the visit, providers conduct a thorough evaluation, reconcile medications, and confirm that the patient understands their follow-up care. This visit is often supported by telehealth, home visits, or office appointments, depending on the patient's condition and preference.
Ongoing Care Coordination
The care team remains in contact throughout the 30-day period, using secure communication channels and care coordination software to track progress, flag concerns, and adjust care as needed. By maintaining continuous contact, we reduce fragmentation and ensure patients stay on track toward recovery.
Engagement and Call to Action
The days and weeks after discharge don’t have to feel uncertain. With Transitional Care Management, you have a dedicated team guiding you every step of the way—checking in, answering questions, and ensuring you’re on the path to full recovery. If you’ve recently been discharged or care for someone who has, talk to your provider about adding TCM services to your care plan. Because going home is just the beginning—staying well is the goal.
