Transitional Care, Remote Physiologic Monitoring, Chronic Care and Principal Care Management

Transit ional Care Managem ent

Transitional Care Management (TCM) services play a crucial role in ensuring smooth and successful care transitions for patients moving from an inpatient hospital setting to their home or a community-based care facility. These services focus on coordinating and managing the patient's healthcare following a critical period after discharge. The aim of TCM is to reduce complications, improve outcomes, and enhance patient satisfaction Proper coordination and management of patients during the immediate post-discharge period may also reduce readmissions

KeyComponentsof TCM:

- Face-to-Face Visit

Following a patient's discharge from an inpatient hospital stay, a face-to-face visit is conducted within 7 or 14 days, depending on the complexity of the medical decision-making involved. During this visit, the physician evaluates the patient's medical condition, reviews the discharge summary, reconciles medications, and develops a comprehensive care plan.

- Communication and Care Coordination:

TCM services involve substantial communication and coordination between the physician, patient, and other healthcare providers This includes arranging necessary follow-up appointments, collaborating with specialists, and facilitating communication between the hospital and post-discharge care settings