Transitional Care Management

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. Transitional Care Management (TCM) services address the hand-off period between the inpatient and community settings. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy.

What is included in care management?

  • A dedicated care team.
  • A comprehensive care plan.
  • Medication and care-management tools.
  • A hospital-to-home program.
  • Patient education materials.
  • Expanded communication between patients and healthcare professionals.

Our goal of the transitional care unit is to assist in recovery by providing the nursing and rehabilitative care necessary to help you or your family member regain a certain level of independence. Depending on the condition, the care may include rehabilitative, restorative, skilled care, or physical therapy.

Medication Management

Medication Management Services are a spectrum of patient-centered, pharmacist provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes. These visits allow our providers to ensure that the medications are working the way that they should and suggest changes if needed. Our provider will discuss any symptoms you still experience, side effects that can occur, and any questions you have. Our hands-on review of medication setup and supplements always uncovers teaching moments. Many patients are out of medicine and do not have an appointment to see a provider. We refill medications and make sure they have a way to get them.