Seamless Care Transitions
Comprehensive support during transitions from hospital to home, reducing readmissions and ensuring continuity of care
What is Transitional Care Management?
Transitional Care Management (TCM) provides comprehensive support to patients during the critical period following hospital discharge. This program ensures smooth transitions between care settings and reduces the risk of complications and readmissions.
Our TCM services begin within 48 hours of discharge and include medication reconciliation, follow-up appointments, care coordination, and ongoing monitoring to ensure patients successfully recover at home.
Critical Transition Points
- Hospital to home transitions
- Skilled nursing facility discharges
- Post-surgical recovery periods
- Emergency department follow-ups
TCM Services Timeline
Structured support throughout the transition period
Within 48 Hours: Initial Contact
Our care team contacts the patient within 2 business days of discharge to assess immediate needs, review discharge instructions, and schedule follow-up appointments.
Days 3-7: Medication Reconciliation
Clinical pharmacists review all medications, identify potential interactions, ensure proper dosing, and address any questions or concerns about new prescriptions.
Days 7-14: Follow-Up Visit
In-person or telehealth visit with primary care provider to assess recovery progress, adjust treatment plans, and address any complications or concerns.
Days 14-30: Ongoing Monitoring
Continued care coordination, symptom monitoring, and support to ensure successful recovery and prevent readmissions during the critical 30-day period.
Reduce Readmissions with TCM
Implement transitional care management and improve patient outcomes while reducing costly readmissions