Seamless Transitional Care Management
Comprehensive support during critical transitions from hospital to home, ensuring continuity of care and reducing readmission risks through coordinated follow-up services.
TCM Service Components
Comprehensive support during the critical transition from hospital to home
Post-Discharge Contact
Interactive contact within 2 business days of discharge to assess patient status and needs.
Timely Follow-Up Visit
Face-to-face or telehealth visit within 7 or 14 days of discharge based on medical complexity.
Medication Reconciliation
Comprehensive review and reconciliation of all medications to prevent adverse drug events.
Discharge Summary Review
Thorough review of hospital discharge instructions and treatment plan modifications.
Care Coordination
Communication with hospital providers, specialists, and community resources for seamless care.
Red Flag Monitoring
Identification and management of warning signs that could lead to readmission.
Benefits of Transitional Care Management
Reduce readmissions and improve outcomes during critical care transitions
Reduced Readmissions
Proactive follow-up and monitoring significantly decrease hospital readmission rates.
Improved Patient Safety
Medication reconciliation and early problem identification prevent adverse events.
Better Outcomes
Coordinated care during vulnerable transition period improves recovery and health outcomes.
Medicare Reimbursement
Eligible for Medicare TCM reimbursement with proper documentation and timely services.
Ready to Implement TCM Services?
Reduce readmissions and improve patient outcomes with comprehensive transitional care
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