Transitional Care Management (TCM)

Your discharge from the hospital, skilled nursing facility, or other qualifying facility is not the end of your healthcare needs. This discharge is the beginning of your transitional care period. Transitional care management exists to ensure continuity of care during this transition period and is designed to last for 30 days – it begins on the date the you are discharged from the hospital and continues for the next 29 days.

Our program includes obtaining and reviewing medication/prescriptions, diagnostics test, lab tests, and coordination of care with other health care providers such as your Primary Care (PCP), Home Health Agency, Home Medical Equipment and Pharmacy. Also, we establish or re-establish referrals for needed community resources.

Our team will help you:

• Discharge Coordination
• Transportation/Pharmacy Pick Up
• New Medication Management
• Home Safety & Fall Prevention Evaluation
• Physician Follow Up Appointments
• Disease Self-Management Training
• Social Determinants of Health Assessment
• Continued Monitoring
• Reduce risk of readmission