Transitional Care Services
Smooth Transitions for Better Health
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Transitional Care Program
Transitional care refers to the coordination of healthcare during a patient’s transition from one healthcare setting to another. The goal of transitional care solutions is to ensure that patients experience a smooth and safe transition, reducing the likelihood of complications, hospital readmissions, and gaps in care.
Transitional Care Services
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Communicate with the Hospital, Post-Acute or inpatient Behavioral Health facility, primary care provider, and ALL other healthcare professionals involved in the patient’s multidisciplinary team
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Perform medication management, reconciliation and education for the patient
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Perform a post-discharge follow-up, by one of three ways: 1) Phone Call 2) Telehealth 3) Home-Visit
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Scheduling and coordinating follow-up appointments and tests
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Educate patients and caregivers to promote understanding of the patient’s condition treatment plan, and self-care techniques
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We can also assume primary care services if the patient doesn’t have an existing PCP or we can return them to their Primary Care Provider once the TCM period ends​
TCM Patients Are Discharged FRom:
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Hospital Setting (Acute Care Setting)
Skilled Nursing Facilities (Post-Acute Setting)
Rehabilitation Centers
Surgery Centers / Surgeons Offices
Total Number of Patients Readmitted Every Year: 17,197,683
Benefits Of Transitional Care Managment
Prevents readmission through early intervention (Saves Hospital money)
Universal reduction in total care costs
Creates a bridge for access to care
Helps patient to overcome discharge barriers
Proactively connects patients with the right services
Supports disease management by optimizing continuity of care
Helps determine correct level of care needed