Transitional Care Management

Care That Continues After Discharge

Refer a Patient

What is TCM?

Transitional Care Management (TCM) helps patients safely move from the hospital back to home or another care setting. It ensures you get the follow-up support you need to recover and avoid unnecessary readmissions.

How it works:

  • Within 2 days: We contact you after discharge to review your needs.

  • Within 7–14 days: You’ll have an in-person or virtual visit with your provider.

  • Within 30 days: We continue to coordinate care, refill medications, and connect you to community resources.

Benefits of Transitional Care

  • For Patients

    Smooth transition from hospital to home

    Early follow-up and support

    Medication review and coordination

    Personalized recovery plan

    Direct access to your provider

    Reduced risk of hospital readmission

    Help connecting to community resources

    Peace of mind for you and your family

  • For Providers

    Lower Costs

    Improved Care Continuity

    Higher Patient Satisfaction Scores

    Reduced Readmission Rates

    Increased Compliance and Quality Metrics

    Strengthened Patient-Provider Relationships

    Supports Population Health Goals

    Evidence-Based and CMS-Endorsed

Refer a patient
Close-up of a patient sitting in a wheelchair in a hospitalroom, with medical equipment and supplies on shelves in the background.

A patient qualifies
for TCM if:

  • They were discharged from an inpatient stay (hospital, SNF, rehab, etc.)

  • Are managing multiple or complex chronic conditions

  • Take multiple medications or have new prescriptions after discharge.

  • Have limited family or social support, live alone, or rely on caregivers.

  • Experience functional decline or have difficulty accessing follow-up care.

  • Face language, transportation, or health-literacy barriers.

  • Are at high risk of readmission or may “fall through the cracks” without coordinated follow-up.

What to expect after Hospital Discharge

Your  30  day Transitional Care Management Journey

  • You’re discharged from the hospital and return home or to another care setting. Your discharge summary and medication list are sent to your TCM provider.

  • Our team contacts you within 2 business days to check how you’re feeling, review medications, and identify any immediate needs or concerns.

  • You’ll meet with your provider (in-person or via telehealth) to review your recovery, discuss medications, and update your care plan. This visit completes your official TCM evaluation.

  • We continue monitoring your progress, helping with refills, referrals, and community resources. If any new symptoms arise, we assist with quick follow-up care.

Smooth transitions, Stronger recoveries

TCM focuses on a patient’s needs during the critical 30-day window after discharge, helping them recover safely, manage medications, and stay out of the hospital.

Refer a patient
Contact Us

Our TCM services follow the highest standards of care set by Medicare, Nevada Medicaid, and Managed Care Organizations.