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Transitional Care Management

Transitional care management is a process designed to ensure that patients receive the care and support they need as they move from the hospital or skilled facility to home.

It is a comprehensive approach to health care that helps bridge the gap between a hospital and a skilled nursing setting. Transitional care management focuses on reducing readmission rates, improving patient outcomes, and increasing cost efficiency. It involves coordinating care between all providers involved in a patient’s care, ensuring that each provider knows the patient’s needs and treatment plans.

In the hospital & skilled nursing setting, you have doctors, nurse practitioners, social workers, case managers, specialists, and much more to help you get better. SC House Calls provides the same style of service, except we bring that right to the comfort of your home.

Before you go home, you will be assigned a case manager, a telehealth provider, an in-home provider, and a pharmacist right away to ensure you have the care you need to keep you from returning to the hospital. We believe in proactive precision care that is there to help you get the healthcare you deserve. We also employ easy-to-use technology like Remote Patient Monitoring to ensure we can catch issues before they worsen.

By utilizing evidence-based practices and the latest technology and tools, it is possible to ensure that patients receive the best care possible and have a positive experience during the transition.

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Frequently Asked Questions

  • Transitional Care Management (TCM) is a set of services provided to a patient during transitioning from one healthcare setting to another. It includes communication and coordination between providers, support for the patient and their family, and ensuring that the patient receives the necessary follow-up care.

  • Services included in TCM may consist of an assessment of the patient’s medical and functional status, medication reconciliation, care planning, medication management, coordination of follow-up care and tests, patient education, and connection to community services and resources.

  • Medicare patients transitioning from one healthcare setting to another, such as from a hospital to a home or a skilled nursing facility, are eligible for TCM services.

  • TCM aims to ensure that patients receive the necessary follow-up care to prevent any potential complications from their transition. It also helps ensure patients receive the best possible care in the most appropriate setting.

  • TCM can help ensure that patients receive the necessary follow-up care and medication management, reducing the readmission risk and improving overall patient outcomes.