Transitional Care Management (TCM) supports patients after discharge through timely follow-up and coordinated care to reduce read missions and improve continuity of care. Delivered by Advanced Practice Providers—including Nurse Practitioners and Physician Assistants—TCM focuses on post-discharge evaluation, medication management, and care transition planning within established clinical protocols.
APPs initiate patient contact within 48 hours of discharge to assess risk, review medications, and ensure follow-up appointments are scheduled.
TCM-trained Nurse Practitioners conduct virtual visits focused on care transition planning, symptom review, and clinical escalation when needed.
APPs coordinate with primary care providers, specialists, and care teams to close gaps and support continuity across settings.
APPs initiate patient contact within 48 hours of discharge to assess risk, review medications, and ensure follow-up appointments are scheduled.
TCM-trained Nurse Practitioners conduct virtual visits focused on care transition planning, symptom review, and clinical escalation when needed.
APPs coordinate with primary care providers, specialists, and care teams to close gaps and support continuity across settings.
Our virtual Transitional Care Management program extends clinical capacity through TCM-trained Advanced Practice Providers, enabling consistent post-discharge follow-up, coordinated care transitions, and improved outcomes—without adding burden to on-site teams or health system overhead.
All APPs operate within structured protocols and physician-aligned workflows to ensure consistency, safety, and compliance.
Increase post-discharge follow-up capacity without recruiting, onboarding, or adding permanent clinical headcount.
Reduce burden on physicians and care managers by offloading TCM activities to experienced Advanced Practice Providers.
Ensure discharged patients receive timely clinical follow-up regardless of payer mix or diagnosis.
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