Transitional Care Management

What is Transitional Care Management?

Transitional Care Management (TCM) typically focuses on the post-discharge period when patients transition from a hospital or other healthcare facility to their home or another setting. It aims to support patients during this critical period to reduce the likelihood of readmissions, and complications, and improve overall health outcomes.

How it Works

Our solutions acts as an enabler to schedule face-to-face appointments, extend care remotely, access real time patient-health information through bi-directional integration with EHRs.

An interactive dashboard with access to patient information and various tools for providers to deliver TCM activities efficiently.

During the transition period from an inpatient hospital to the community setting, TCM servicing generally fall into three categories.

Transitional Care Management Services provide support to patients as they move between different healthcare settings or stages of care, promoting seamless transitions, enhancing results, and minimizing potential complications.

Why choose TUCWC's Transitional Care Management?

Our HIPAA-compliant cloud-based software application is designed specifically for managing patients in care transitions. It automates your entire care transition workflow – from enrolling the patient and creating the electronic care plan to reconciling medications, scheduling & documenting phone calls, and generating reports needed for billing purposes.

Interactive Contact

This can be made via email, telephone, or face-to-face contact within 2 business days following a patient’s discharge to a community settings.

Non face-to-face Service

Obtaining/reviewing discharge information, connecting with healthcare professionals, education and support for scheduling follow up, treatment regimen adherence and medication management.

Face-to-face Visits

Face-to-face visits may also be completed, generally within 7 to 14 days depending on Medical decision complexity of the patient being discharged from the hospital.

Key Features

Education Transfer

Providing seamless knowledge transfer to the patient or caregiver.

Ease Of Use

Allowing ease of use and incorporation into existing workflow

Interactive Contact

Initiating an interactive contact with the patient within the first two days of discharge.

Care Coordination

Determining any needs that exist by coordinating care with community organizations for the patient.

Discharge Summary

Reviewing the discharge summary and discharge instructions with the patient or caregiver.

Medication Reconcillation

Providing medication reconciliation.

Easy Care Transfer

Coordinating care with other health care professionals who may assume or resume care.

Follow-up reminder

Scheduling and automatically reminding the patient of required physician follow-ups or additional services.

Transitional Care Management

What is Transitional Care Management?

How it Works