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Blog: Transitional Care Management

What Exactly Is Transitional Care Management (TCM)?

You’ve probably seen first-hand or have heard from friends or family how patients who don’t receive adequate levels of after care services can often wind up getting sick again and/or need to be readmitted.

Transitional Care Management (TCM) addresses the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, a new diagnosis, or change in medication therapy.

Dementia, heart disease, COPD, diabetes, and other chronic conditions can often be managed in the patient’s community setting. When there is an interruption in care while the patient is being transitioned from inpatient to in-home care, however, it can put the patient at risk for relapse and increases the risk for readmission. TCM exists to ensure continuity of care during this transition period.

TCM is designed to last 30 days. The essence of TCM is that a health care provider takes charge of the patient’s care from the instant he or she has been discharged. It involves a medical professional engaging in one face-to-face visit with the patient, and then additional non face-to-face meetings (such as by telephone or a video call, as is the case with telemedicine).

Transitional care management is an important piece of the puzzle for monitoring and managing chronic conditions. As more and more seniors want to continue living independently for as long as possible, TCM helps ensure that the patient’s needs are being.