Transitional Care Management

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.

Transitional Care Management

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:

Recently Discharged Hospital Patients

Ensuring adherence to post-operative health metrics and managing recovery. Especially those who require complex care post-discharge.

Elderly Patients with Multiple Comorbidities

Assisting in managing transitions between care settings for individuals with complex health needs.

Patients with Acute Conditions Requiring Post-Hospital Care

Such as heart failure, pneumonia, or surgeries requiring post-operative care.


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.

Discover why DHI is the preferred choice for individuals seeking comprehensive and personalized healthcare outcomes
Prefer to sign up over the phone? Speak to an DHI advisor today at
Skip to content