Transitional Care Management (TCM)

RoadL offers comprehensive Transitional Care Management (TCM) services designed to ensure a smooth transition for patients moving from an inpatient care setting back to their community or home. Our approach focuses on reducing readmission risks, addressing immediate healthcare needs, and providing personalized care coordination.

What Is Transitional Care Management?

TCM bridges the gap between hospital discharge and home-based recovery. It includes a range of services that help patients manage their health post-discharge while addressing any medical, psychosocial, or functional challenges they may face.

Key Components of TCM

Initial Communication

Timely Contact: (HRA)

Face-to-Face Visit

A follow-up visit is scheduled based on the complexity of the patient’s medical needs:

Comprehensive Care Coordination

Our team ensures seamless coordination of all aspects of the patient’s care:

Medication Reconciliation and Management:

Collaboration:

Social Determinants of Health:

Addressing Patient Needs During TCM

Chronic and Acute Condition Management

• Update and adjust chronic disease treatment plans.
• Provide care for acute conditions identified during or after hospitalization.

Risk for Readmission

Identify risks such as:
• Poor medication adherence.
• Inadequate understanding of discharge instructions.
• Lack of support at home or in the community.
• Create a tailored plan to reduce readmission risk.

Psychosocial and Functional Assessments

• Evaluate mental health, emotional well-being, and coping strategies.
• Identify any functional limitations or mobility issues.

Educating Patients and Caregivers

Reinforcing Discharge Instructions

Provide clear, written materials that are easy to understand. Highlight critical red flags and outline when to seek medical attention.

Engaging Caregivers

Ensure caregivers are informed about their role in supporting the patient’s recovery.

Follow-Up Planning

Schedule appointments with primary care providers or specialists. Arrange necessary diagnostic tests or lab work. Provide referrals to community resources or support services, such as home health care or physical therapy.

Why Choose RoadL for TCM?

Patient-Centered Approach:

Seamless Coordination:

Improved Outcomes:

Take the next step toward a smooth recovery with RoadL. Contact us to learn more or to schedule your TCM visit.