Transitional Care Management

The Transitional Care Management (TCM) program is designed for patients who have been discharged from hospitals or other facilities. TCM involves a health care provider engaging the patient in a combination of face-to-face and telehealth visits for a period of 30 days. These health care provider visits ensure there are no gaps in patient care and prevent unnecessary patient hospitalizations. 

A nurse examining a sick senior woman lying in bed at home with stethoscope.
Nurse examining elderly woman with glucometer at home
  • Contact within 24 hours of discharge to coordinate you first in-home visit
  • Full medication review, home safety evaluation, and clinical assessment
  • Discuss your health care goals and personalize a care plan specific to your needs
  • Specialized education programs and protocols to fit your recovery needs
  • Virtual Check-In’s from our nursing and/or therapy teams
  • Assistance with community resources and follow-up appointments
  • Easy navigation to inpatient and outpatient rehabilitation settings as needed
  • 24/7 access to on-call nurse for urgent concerns