Our Transitional Care Management (TCM) team assists with the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. With regular visits from a Nurse Practitioner, our TCM services enhance quality of care, improve patient outcomes, reduce readmission rates, and boosts patient satisfaction. In addition, there is no co-pays or fees, so the it does not cost patients anything.

 

Transitional Care Management services involve a transition of care from one of the following hospital settings:

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• Inpatient acute care hospital

• Inpatient psychiatric hospital

• Long-term care hospital

• Skilled nursing facility

• Inpatient rehabilitation

• Hospital outpatient observation

• Partial hospitalization