Transitional Care Management
High-Quality Transitional Care After Discharge
The first 30 days after discharge is when readmission risk is the highest. Our TCM program provides intensive follow-up care and coordination to prevent complications and keep you safely at home.
What Is Transitional Care Management?
Transitional Care Management (TCM) is a Medicare-covered service designed to support patients during the high-risk period immediately following discharge from a hospital, skilled nursing facility, or inpatient rehabilitation center.
During this vulnerable window, patients are at higher risk for complications, medication errors, and preventable readmissions. Our dedicated APRNs bridge the gap — coordinating with your hospital team, primary care provider, and specialists to ensure nothing falls through the cracks.
Who Qualifies for TCM?
You may be eligible for Transitional Care Management if you were recently discharged from any of the following settings:
TCM services are covered under Medicare Part B and most private insurance plans. Our team will verify your coverage as part of the enrollment process.
How Our TCM Program Works
From the moment you're discharged, our care team is with you every step of the way.
Early Contact After Discharge
Your dedicated APRN reaches out by phone shortly after discharge to assess your condition, review discharge instructions, and identify any immediate concerns.
In-Person Follow-Up Visit
A face-to-face visit with your care team is scheduled based on your needs and complexity. We review your medications, symptoms, and recovery progress.
Medication Reconciliation
We conduct a thorough review of all your medications — comparing what was prescribed in the hospital with what you were taking before — to prevent dangerous interactions or missed doses.
Care Coordination & Follow-Up
We coordinate follow-up appointments with your primary care provider and any specialists, communicate your care plan across your entire healthcare team, and remain available for questions throughout your recovery.
Why Patients Choose Our TCM Program
Dedicated APRN
You'll have one consistent point of contact who knows your history, your goals, and your care team.
Responsive Care Team Access
Have a question or concern after discharge? Our care team is here to provide guidance and support when you need it.
Medication Safety Review
Medication errors are a leading cause of readmission. We reconcile every prescription to keep you safe.
Specialist Coordination
We schedule and track follow-up appointments with all your specialists so nothing gets missed.
Family & Caregiver Support
We include your family and caregivers in the care plan so everyone is informed and prepared.
Covered by Medicare
TCM is a fully covered Medicare Part B benefit. Most patients pay little to nothing out of pocket.
Ready to Enroll in TCM?
If you or a loved one was recently discharged from a hospital or care facility, our team is ready to help. Reach out to get started.
Questions? Call us at (702) 832-8746
Are you a provider or discharge planner? Refer your patients directly.