Transitional Care Management (TCM) focuses on ensuring a smooth transition for you as you move from one care setting to another, typically from an inpatient to an outpatient environment.
During these transitions, primary care physicians (PCPs) play a pivotal role in closing gaps in care that are beyond your control. Your PCP will make sure discharge plans are clear to you and your caregivers, if applicable, and will make sure you have adequate care after visiting an inpatient facility.
Required patient Transitional Care Management (TCM) services include:
Assessment and Planning
Comprehensive assessment of your health status, medical history, and treatment needs.
Development of a transition plan outlining the steps and responsibilities for the transfer of care.
Identification of any potential barriers or challenges to the transition process.
Communication
Coordination of communication between sending and receiving healthcare providors.
Sharing of relevant patient information, including medical records, test results, and treatment plans.
Ensuring that all involved parties are informed and prepared to continue providing appropriate care.
Medication Management
Medication reconciliation to ensure accurate and up-to-date medication lists.
Review of medications to identify any discrepancies, interactions, or changes needed.
Patient education on medication regimen, including instructions for use, potential side effects, and follow-up monitoring.
Coordination of Care
Facilitating referrals to specialists, rehabilitation services, or other healthcare professionals.
Patient Education and Support
Providing information and resources to help you and your family/caregivers understand and manage the transitional process.
Offering guidance on self-care, symptom management, and coping strategies.
Educating you/family/caregiver on community resources or support services for additional assistance as needed.
