Transitional Care Management (TCM)

We provide first-class transitional care that your patients deserve. No matter the reason for admission and regardless of the facility, our practitioners perform in-home evaluations, educate and communicate to enhance the transition of care for patients.
HIPAA Compliant
Integrated Care
24/7 Access
Reduced Readmissions
Improved Outcomes

TCM: The First Step in Preventing Readmissions

TCM helps prevent patient rehospitalizations by providing physicians and their patients on-demand access to experienced Physician Assistants and Nurse Practitioners.  Our stream-lined program is led by dedicated skilled clinicians that identify patient's post-discharge care needs. Using a holistic approach, we triage and expertly manage care across multiple providers. 

We Handle the Details:

  • Contact the patient within 24 hours following discharge
  • Face-to-face and non-face-to-face encounters
  • In-Home visits as medically necessary
  • Ensure follow-up physician offices visits are made
  • Provide all billing and coding details to ensure maximum reimbursement 

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Transitional Care Management from Any Facility

Inpatient Acute Care Hospital

Inpatient Psychiatric Hospital

Long Term Care Hospital

Skilled Nursing Facility

Inpatient Rehabilitation Facility

Hospital outpatient observation or partial hospitalization

Partial hospitalization at a Community Mental Health Center