Transition of Care Management (TCM)

The first 30 days post hospital admission is a very critical time frame for you as the patient. This is most often when moderate or high-complexity medical issues can occur. During this period, chances of readmission increase if proper transition and quality of care are not provided.

Transitional Care Management (TCM) is a paid, preventive wellness program. It was started by the Center for Medicare and Medicaid Services (CMS) to provide patients with post discharge follow up services. The goal of the program is to eliminate gaps in your healthcare to avoid medical errors in followup, by reviewing your discharge instructions with a TCM nurse within 2 days post inpatient admission and a face-to-face visit with your provider 7-14 days after discharge.

What can you expect as the patient?

You will receive a call from our TCM coordinator. She/he will reconcile any changes in medications and go over discharge instructions with you. Oftentimes, as a patient you may need guidance on what your next steps are after you have been discharged. She/he will schedule you to see your primary care provider, review any new medications or changes in any of your current medications and help to coordinate any follow up appointments you may need. She/he will help to identify any barriers you may have in follow through with the plan of care upon discharge, for example; transportation to get medications or appointments. This will all help to reduce your potential for readmission and support you through the transition from inpatient to outpatient.

• Inpatient acute care hospitalInpatient psychiatric hospital
• Long-term care hospital
• Nursing home
• Inpatient rehabilitation center
• Hospital outpatient observation/partial hospitalization
• Patients who receive this TCM service typically see as high as an 86% decrease in the odds of readmission compared with patients who did not receive TCM services.

You can reach TCM nurse:

Monday, Tuesday and Thursday
8:00am – 4:30pm
603-447-3500 ext. 218