Transitional Care Management

Patient with Healthcare Nurse

Returning home after an acute or skilled stay can be overwhelming. Transitional Care Management (TCM) bridges the gap between an inpatient stay and care in your home. This extra support can help patients adjust to their new medications and care routines, learn to cope with changes in functional status, and manage barriers to successful self-management. The goal of our Summit Medical Consultants Care Management Team is to support the needs of the patient and prevent deterioration or readmission. Once enrolled, patients will be provided with 30 days of care management services after discharge. 

 

TCM Services include the following:

  • Initial Contact and Face-to-Face Provider Visit

    • Obtaining and reviewing any discharge information

    • Reviewing follow-up diagnostic tests or treatments

    • Providing education to the patient and family members or care-givers

    • Establishing referrals and arranging for community resources

    • Assistance in scheduling the follow-up visit with their physician

  • 30 Day Follow-Up Care

    • Weekly phone calls with a nurse to provide ongoing support and assistance after discharge for 30 days after discharge