Transitional Care Management Program
Supporting you after facility discharge
TCM is a Medicare-approved program that helps patients transition safely from a hospital or skilled nursing facility (SNF) back to home or another care setting. For our program, we focus primarily on patients discharged from an SNF.
How the TCM Program Works
1. CONTACT AFTER DISCHARGE (within 2 business days)
Our care coordination team will call within 48 hours after discharge to check on symptoms, review instructions and medications, and schedule your follow-up visit with a provider.
2. FOLLOW-UP-VISIT (within 7 or 14 days)
You will have a virtual (video) visit with our provider: within 7days if your condition is high risk, or within 14 days if moderate risk. During the visit, we review your care plan and if needed, modify it as appropriate in response to your symptoms and current situation.
3. Ongoing Coordination
We coordinate with your primary care and specialists, arrange services, and help prevent re-admissions.
Benefits of TCM
- Reduces risk of hospital re-admission
- Improves medication management and understanding
- Enhances communication amoung your care team
- Promotes faster recovery and peace of mind
- Provides ongoing support for you and your family
What You Need to Do
- Keep your phone available after discharge so we can reach you
- Bring all medications (or a list) to your follow-up visit
- Contact us if symptoms worsen or if you have trouble getting medications or equipment