Transitional Care Management (TCM) focuses on supporting patients as they transition between different levels of care, especially after hospital discharge.
It involves managing the transition from hospital to home or other care settings, ensuring continuity of care and reducing the risk of readmissions.
Key Features:
Post-Discharge Follow-up
Close monitoring and follow-up care after hospital discharge to ensure proper recovery and adherence to post-hospital health metrics.
Medication Management
Reviewing and managing medication regimens, ensuring proper understanding and adherence to prescribed medications.
Care Coordination
Coordinating care between different healthcare providers to ensure a smooth transition and continuity of care.
Suitable For:
Ensuring adherence to post-operative health metrics and managing recovery. Especially those who require complex care post-discharge.
Assisting in managing transitions between care settings for individuals with complex health needs.
Such as heart failure, pneumonia, or surgeries requiring post-operative care.
Benefits:
Reduced Readmissions
Ensures patients receive proper care and support post-discharge, reducing the risk of complications and readmissions.
Improved Recovery
Close monitoring and support contribute to better recovery and adherence to post-hospital health metrics.