Transitional Care Management

Preventing avoidable hospital admissions is a top priority for ensuring patient safety and quality of care, especially for those transitioning from hospitals, skilled nursing facilities/Rehab/ back to their homes. Poor communication and coordination during these transitions is a leading cause of preventable readmissions, particularly for our older adults population and those with multiple comorbidities. These transitions occur between various care settings, including acute-care hospitals, long-term care facilities.

Unfortunately, inadequate coordination between acute-care facilities and primary care providers often leads to subpar long-term care planning. Shockingly, less than half of patients see their primary care providers within 2 weeks of hospital discharge.

To address this issue, we provide comprehensive programs to improve care during transitions between settings. Our Transitional Care Management (TCM) programs have been shown to significantly reduce both 30-day hospital readmissions and readmissions over the course of a year after the initial hospitalization.