Transitional Care Management
Coordinated Medicare primary care designed to help seniors remain healthy, independent, and safely at home.
Preventing Hospital Readmissions
The period immediately following a discharge from the hospital or skilled nursing facility is the most vulnerable time for any senior. Medications are frequently altered, mobility may be reduced, and new therapies are introduced. Without dedicated oversight, nearly 20% of Medicare patients find themselves readmitted to the hospital within 30 days.
Transitional Care Management (TCM) is a 30-day intensive program designed to provide high-touch support the moment you leave the hospital. At Primary Clinic Senior Care, our clinical team takes immediate ownership of your recovery. We coordinate fiercely with hospital discharge planners, review your updated medications, and ensure you receive a comprehensive clinical evaluation within days of returning home.
Real-World Outcomes
Medication Safety
Hospital doctors often change your prescriptions. We perform a rigorous reconciliation to ensure you aren't accidentally taking duplicate or conflicting medications once home.
Faster Recoveries
By verifying that your home health therapies and medical equipment orders have actually been processed, we prevent delays in your rehabilitation.
Lower Readmission Rates
TCM is statistically proven to drastically reduce the likelihood that a patient will suffer a setback requiring an emergency return to the hospital.
Who requires Transitional Care?
TCM is designed for Medicare beneficiaries who require moderate to high complexity medical decision-making following a discharge from:
- • An inpatient acute care hospital
- • A skilled nursing facility (SNF)
- • An inpatient rehabilitation facility
- • A long-term care hospital
- • Hospital outpatient observation status
For Hospital Discharge Planners
Discharging high-risk patients without a reliable primary care follow-up is dangerous. Partner with Primary Clinic Senior Care to guarantee that your complex seniors will receive clinical contact within 48 hours of leaving your facility.
What to Expect
48-Hour Contact
Within two business days of your discharge, our clinical staff will contact you to verify you have arrived home safely, assess your immediate symptoms, and ensure you have access to your medications.
Timely Medical Evaluation
Depending on the complexity of your condition, we will conduct a comprehensive virtual evaluation within 7 to 14 days of discharge to formally review your status and update your care plan.
30 Days of Intense Coordination
For a full 30 days, we manage the transition. We track pending lab results, coordinate with your home health agency, schedule follow-up appointments with specialists, and provide ongoing education to your caregivers.
Frequently Asked Questions
Do I need to see you in person for this visit?
No. Leaving the house right after a hospital stay can be dangerous or impossible for many seniors. We conduct TCM evaluations via our secure virtual telehealth platform, so you can recover in your own bed.
Is Transitional Care Management covered by Medicare?
Yes. TCM is a highly prioritized service recognized by Medicare. Standard Part B deductibles and coinsurance generally apply to the evaluation visit.
What happens after the 30-day TCM period?
Once your recovery stabilizes at the 30-day mark, we seamlessly transition you into our Advanced Primary Care Management program for ongoing, continuous oversight.
Secure Your Path to Recovery
The transition from hospital to home requires expert coordination. We are here to guide you through it. Coordinated Medicare primary care designed to help seniors remain healthy, independent, and safely at home.