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Transitional Care ManagementThe thirty days after hospital are the riskiest.
Most people go home with medications that changed, appointments nobody booked, and no clear idea who to call. Transitional Care Management is the program built to close that gap.
A proper handover, not a phone call.
Transitional Care Management is a Medicare program covering the thirty days after you leave a hospital or facility. A clinician takes responsibility for that window — reaching you quickly, seeing you in person, sorting out your medication list, and staying reachable while things settle.
It exists because that first month is when people get into trouble. Not from the original illness, usually, but from the gaps around it.
What happens, and when
These are not internal targets. They are the deadlines Medicare sets for the program, and the documentation has to show they were met.
You leave hospital
Discharge day. The thirty-day window starts here — whether you are going home, or on to rehab or a nursing facility first.
We reach you
A member of the team contacts you or your caregiver. Business days mean Monday to Friday, not counting federal holidays — so a Friday discharge means we reach you by Tuesday.
You are seen in person
A face-to-face visit with a clinician. Within seven days if your situation is complex, within fourteen otherwise. Your medications are reconciled by this visit at the latest.
We stay with it
Coordination with your other doctors, chasing test results, answering questions, and adjusting what is not working — for the rest of the thirty days.
Six things that go wrong, handled
Medication reconciliation
People often come home on a different list than they went in with. We go through every medication — what stopped, what started, what interacts — and make sure one accurate list exists.
Follow-up that actually happens
Discharge paperwork names appointments nobody booked. We arrange them, and make sure the specialist has what they need before you arrive.
Pending results chased down
Tests ordered in hospital often come back after you have left. We track them and act on what they show, rather than waiting for the next crisis.
A number that gets answered
Most post-discharge problems are small and fixable if someone hears about them on day three instead of day twelve. You get someone to ask.
Your other doctors kept in the loop
We send what happened to your primary care provider and your specialists, so nobody is working from an out-of-date picture.
Help understanding what changed
Plain-language explanation of the diagnosis, the new medications and the warning signs to watch for — for you and for whoever is caring for you.
Coming home from any of these
The program applies when you are discharged to a community setting after:
- A hospital inpatient stay
- A skilled nursing facility
- An inpatient rehabilitation facility
- An inpatient psychiatric hospital
- Hospital observation or partial hospitalization
Not sure whether it applies? Call and we will tell you honestly — and point you elsewhere if it is not the right fit.
Before you ask
The things families ask us most often about this program.
Is this something extra I have to pay for?
Transitional Care Management is a Medicare-covered service, billed like a physician visit. Normal Medicare cost-sharing applies. Our team verifies your benefits before the first visit so there are no surprises.
Do I have to leave my own doctor?
No. Transitional Care Management does not replace your primary care provider or your specialists. It covers the specific thirty-day window after discharge, and part of the work is making sure your existing doctors know what happened.
What if I was discharged to rehab or a nursing facility first?
The program applies once you are discharged to a community setting. If you are heading to a facility first, we follow you and pick the clock up when you leave there — that discharge is treated as its own episode.
Is this the same as palliative care?
No. Transitional Care Management is time-limited — thirty days, tied to a discharge. Palliative care is ongoing support for people living with serious illness, and it can run for years. Some people move from one to the other.
Who can refer?
Physicians, hospitalists, discharge planners, case managers, social workers, facilities, families, and patients themselves. You do not need a formal referral to start the conversation — call and we will work out whether the program fits.
Discharge planners, hospitalists and case managers
We accept transitional care referrals from all three of our partner hospitals and from skilled nursing, rehab and assisted living facilities across the DFW area. Send the referral and we take the two-business-day clock from there.
Going home should not feel like being dropped.
One call starts it. If the program is not the right fit, we will tell you that too — and help you find what is.