Transitional Care Management (After Hospital Discharge)




Being discharged from the hospital can be a trying time for your loved one as they learn how to manage their recovery or adjust their lifestyle due to a new diagnosis. To ensure a smooth transition from hospital to home, transitional care management (TCM) is available to coordinate all health-related needs and manage the necessary home-based care.


TCM typically assists within 14 to 30 days after someone has been discharged from an inpatient setting, such as a hospital. Management during these first 30 days after discharge is crucial because the likelihood of readmission increases if proper transition and quality of care are not provided.


The benefits of TCM are enormous, with an 86% decrease in readmission risk for those who receive TCM services.


The Components of TCM

There are three primary components of TCM, all set to occur within the 30 days after discharge. The primary goal of these three components is to ensure there is no gap in healthcare during this crucial time period.


Initial Contact

TCM requires an initial contact with the client within 2 days of the inpatient-facility discharge. Transitional care managers can make this contact through three methods: face-to-face, telephone, or email.


Non-Face-to-Face Services

Following the initial contact, TCM then supplies non-face-to-face services until the care manager determines that they are no longer needed, based on the health and medical needs of the client. In addition to the transitional care manager overseeing these non-face-to-face services, their staff can also assist as directed by them.


Some of the activities within this category include:

  • Collaborating with healthcare professionals and other care team members who will be in charge of caring for the patient.

  • Scheduling the required follow-ups with the patient’s providers/services.

  • Assess and support the adherence to the treatment regimen, which can include medication management.

  • Identifying and communicating with agencies, community services, and health resources.


Face-to-Face Visit

The final aspect of TCM is a face-to-face visit, which may fall within two categories. Those who need TCM for a medical decision of moderate complexity require a face-to-face visit within 14 days of discharge. In contrast, those with a high medical decision complexity must have a face-to-face visit within 7 days of discharge.


The complexity of the medical decision is determined based on

  • number of diagnoses

  • amount of care management options needed

  • the complexity of medical records

  • risk of significant complications

  • comorbidities


Benefits of TCM

The single most beneficial aspect of TCM is the reduced number of readmissions. Not only does this ensure better care and health for your loved ones, but it also improves their morale since they won’t have to spend as much time in the hospital.


Another benefit of placing your loved one’s care in a transitional care manager’s hand is that the quality of care will be better. TCM focuses on ensuring your loved one’s discharge orders are properly followed, and additional concerns regarding their care are managed to make this transition as seamless as possible.


If you are interested in TCM for your loved one following a hospital discharge, reach out to us at (404) 310-3567 or schedule a free consultation. We can match you with a transitional care manager who can handle all aspects of your loved one’s care, allowing you and your loved one to focus solely on healing and adapting to any lifestyle changes.