Transitional Care Management Services to Medicare Patients

In order to reduce readmissions and improve patient outcomes, we will begin providing Transitional Care Management (TCM) services to Medicare patients following hospital discharge. The initial pilot will include patients admitted by Cardiology services. Nurses will be prompted by a BPA to provide a TCM pamphlet and patient education prior to discharge.

TCM includes services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions from in-patient settings back to the patient's community surroundings. The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days.

For more details, take a look at the MLN Fact Sheet on cms.gov.

What is Transitional Care Management (TCM)?

TCM ensures that the patient receives concentrated care and attention in the crucial first 30 days immediately following a hospital stay. A representative from University Physicians will reach out to them after discharge to ensure he/she is taking all medications correctly, getting any necessary tests, understands discharge instructions, and has a follow-up appointment within 2 weeks of discharge.

The TCM program is designed to help the patient know what medications have been prescribed, how to obtain them, and how to take them. The program aims to educate patients on what symptoms to watch for and who to call if the symptoms are noticed.

Overall, the goal is to help keep health problems from becoming worse.