Transitional Care Management
Transitional Care Management (TCM) is a program that provides services for individuals who need help during transitions in care from an inpatient setting (including acute hospital, rehabilitation hospital, long-term acute care hospital or skilled nursing facility) to the patient’s home.
How does the program work?
A Transitional Care Specialist will visit you at the hospital or at home to explain the benefits of the program. Then a home nurse visit will be set up to evaluate your needs.
The Program can help you:
Stay safe and stable at home to avoid unnecessary visits to the hospital
Set goals or your health
Prepare for your routine visit to your primary care doctor
Answer questions and concerns you may have regarding your condition
Learn about your symptoms and how to treat them
Teach you about your health condition and your medications
Your care specialist will:
Help with your medications
Show your caregiver and or your family how to care for you
Assist with urinary catheter health
Start and monitor at home IV Therapy
Apply dressing change and wound care
Provide nursing consultation
Teach you about diabetes care
Your care team is available 24 hours a day, 7 days a week to answer any questions and visit you at home when needed.
Advanced Care Planning
Qualified health care professionals working to help you identify your needs, goals and medical treatment preferences, Once the first step is completed they will help you select the most appropriate Advanced Care Directive. The goal is to ensure that you select a health care agent that you trust and feel comfortable with and receive the treatment you want when you can no longer make those decisions for yourself.
POLST Advanced Health Care Directive