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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