Transitional Care Management

Transitional Care Management

Transitional Care Management involves the transitioning of a patient from an emergency department (ED) or inpatient (hospital, skilled-nursing facility, short-term rehab, etc.) stay from the facility back to their home. FamilyCare Medical Group utilizes Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) who assist in ensuring that a recently discharged patient receives a phone-call within two business days post discharge to review the patient’s discharge summary and ensure that the patient fully understands the information contained within it.

The nurse will also schedule a follow-up appointment with the patient and their PCP within 2 calendar days for those identified as “high-risk” patients, 7-14 days for those with “moderate risk” and within 30 days for all others (depending upon the medical necessity of the patient). In providing this service, FamilyCare Medical Group patients have a decreased risk for readmission due to social determinants of health, medication errors or failure to recognize the signs and symptoms of a reoccurrence of their acute episode.