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Comprehensive Post-Acute Care for Better Outcomes
What is Transitional Care Management (TCM)?
Transitional Care Management (TCM) is a critical service aimed at ensuring a smooth transition for patients moving from a hospital or other acute care setting back to their home. Unlike general coordination of care, TCM is a specific Medicare service designed to provide thorough follow-up and management of a patient’s condition after discharge. This dedicated approach helps manage all aspects of a patient’s health, significantly reducing the risk of hospital readmission.
Our TCM Services
At Doctors House Calls, we offer robust Transitional Care Management services that include:
- Initial Contact: We will reach out to you within two business days after your discharge to schedule an in-home visit.
- In-Home Visit: Within seven to fourteen days post-discharge, one of our experienced providers will visit your home to conduct a thorough assessment of your health and any changes in your medical condition.
- Medication Reconciliation: We will review and reconcile your medications to ensure they are accurate and aligned with your current health needs.
- Comprehensive Care Plan: Based on your assessment, we will create a personalized care plan tailored to manage your current condition effectively.
- Coordination with Specialists: If necessary, we will coordinate with any specialists involved in your care to ensure a seamless transition and comprehensive management of your health.
The Importance of TCM
Medicare recognizes the importance of continuous, proactive care for patients who have recently experienced a significant health event requiring hospitalization. The primary goal of TCM is to ensure that your primary care provider is fully aware of any and all medical changes that occurred during your hospital stay. This allows for a more comprehensive understanding and management of your current condition, enhancing your overall health and reducing the likelihood of complications or readmission.
Reduced Hospital Readmissions
By closely monitoring your health and managing any changes, we help minimize the chances of needing to return to the hospital.
Personalized Attention
Our providers spend more time with you, addressing all aspects of your health and ensuring you fully understand your care plan.
Convenience
All services are provided in the comfort and safety of your home, eliminating the need for travel and reducing stress.
Comprehensive Support
From medication management to coordinating follow-up care, we handle every detail to ensure your recovery is smooth and successful.
Why Choose Doctors House Calls for TCM?
With over 25 years of experience in providing high-quality in-home medical care, Doctors House Calls is dedicated to delivering personalized, patient-centered services. Our commitment to excellence ensures that you receive the best possible care during your transition from the hospital to home, promoting better health outcomes and peace of mind.
Experience the difference of comprehensive, compassionate care with Doctors House Calls. For more information or to schedule your Transitional Care Management visit, please contact us.
