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:
- A member of our team will reach out to the patient (or caregiver) within two business days of discharge.
- Purpose: Assess immediate needs, confirm patient status, and reinforce follow-up care instructions.
Face-to-Face Visit
- A follow-up visit is scheduled based on the complexity of the patient’s medical needs:
- High Complexity: Within 7 calendar days.
- Moderate Complexity: Within 14 calendar days.
Comprehensive Care Coordination
Our team ensures seamless coordination of all aspects of the patient’s care:
- Medication Reconciliation and Management:
- Review and adjust medications to avoid adverse effects or interactions.
- Collaboration:
- Work with healthcare providers, specialists, and community resources to meet patient needs.
- Social Determinants of Health:
- Address factors like transportation, financial barriers, and home support.
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: Tailored care plans focused on individual needs and recovery goals.
- Seamless Coordination: Effective collaboration between healthcare teams and resources.
- Improved Outcomes: Reduce readmission rates and support patients in achieving a full recovery.
Take the next step toward a smooth recovery with ROADL. Contact us to learn more or to schedule your TCM visit.
