Home / Our Care
Transitional Care ManagementThe thirty days after leaving the 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.
The bridge between hospital and home.
Transitional Care Management is a Medicare-covered program that provides support during the 30 days following a hospital or facility discharge. The first month after hospitalization is often when patients need the most support. Our provider-led telehealth visits help patients understand their care plan, manage medications, monitor symptoms, and stay connected to clinical guidance during the transition home.
By staying involved during these critical 30 days, we help patients recover safely, close gaps in care, and avoid unnecessary trips back to the hospital.
A Better Transition Home Starts Here
The weeks following a hospital discharge are often the most vulnerable. Our team engages patients early, addresses concerns quickly, and provides ongoing clinical support to promote a safer recovery at home.
The Transition Begins
When a patient leaves the hospital, our team reviews the discharge plan, identifies potential risks, and prepares for timely follow-up. This early oversight helps ensure patients have the support they need from the start.
We Reach Out
A member of our clinical team contacts the patient or caregiver to review medications, assess symptoms, answer questions, and address concerns before they become barriers to recovery.
Provider Follow-Up
Patients meet with one of our providers within the Medicare-required timeframe. We perform medication reconciliation, evaluate recovery progress, address clinical needs, and coordinate care with the patient’s existing healthcare team.
Ongoing Support
Our team stays actively engaged through regular check-ins, symptom monitoring, medication support, and care coordination. By remaining involved during this critical recovery period, we help patients stay on track and reduce the risk of unnecessary hospital readmissions.
Common Challenges, Proactively Addressed
Medication Reconciliation
Getting medications right
Hospital medication lists often change. We carefully review every medication, identify discrepancies, and make sure patients understand what they should be taking.
Quick Access to a Provider
Answers when they matter most
Questions and concerns don’t always happen during scheduled appointments. If new symptoms arise, medications need adjustment, or refills are required, patients have timely access to a provider who can quickly schedule a visit, address concerns, and help prevent unnecessary trips to the ER.
DME Coordination
The equipment you need, without the delays
Whether it’s a walker, wheelchair, hospital bed, oxygen, or other medical equipment, our team can assess needs and help coordinate appropriate DME orders after discharge.
Home Health Coordination
Keeping everyone on the same page
We work closely with home health agencies and can review and sign plans of care when appropriate, helping ensure services continue seamlessly and patients receive the support they need.
Specialist & Follow-Up Coordination
Making sure follow-up actually happens
We help coordinate appointments, communicate with specialists, and ensure important follow-up care doesn’t fall through the cracks after discharge.
Resource Navigation
Connecting patients to additional support
When needs extend beyond medical care, we help connect patients and families with trusted community resources, caregiver support, transportation assistance, and other available services.
Supportive Palliative Care & Symptom Management
Relief from pain and difficult symptoms
For patients living with serious illness, we help manage pain, shortness of breath, fatigue, nausea, and other symptoms to improve comfort and quality of life.
Ongoing Monitoring & Check-Ins
Staying ahead of potential setbacks
Regular follow-ups allow us to monitor recovery, identify concerns early, and provide ongoing support throughout the critical transition period.
Recently Discharged? We’re Here to Help.
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 begins when you are discharged home or to another community setting. If you first go to a rehabilitation, skilled nursing, or other facility, we will stay connected with your care and start the program when you leave that facility. That discharge starts a new care transition period.
Is this the same as supportive palliative care?
No. Transitional Care Management is time-limited: thirty days, tied to a discharge. Supportive 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 hospitals, skilled nursing, rehab and assisted living facilities across the DFW area.
Recovery Is a Journey. We’ll Walk It With You.
One call starts it. If the program is not the right fit, we will tell you that too, and help you find what is.