Transitional Care Management

 

• A 30-day TCM period begins on a patient’s inpatient discharge date and continues for the next 29 days. TCM services begin the day the patient is discharged from either an Inpatient Acute Care Psychiatric Hospital or Inpatient Rehab Facility, Long-Term Care Hospital, Skilled Nursing Facility, hospital outpatient observation or partial hospitalization, partial hospitalization at a Community Mental Health Center after inpatient discharge. The patient must return to their community setting either to home, domiciliary, rest home or assisted living.
• Within 2 business days following the patient’s discharge, you must contact the patient or their caregiver via phone, email, or face-to-face. Clinical staff can address patient status and needs beyond scheduling follow-up care.
• Preventive Care.

Measurable, system-based approaches are applied to ensure the patient receives all recommended preventive care services in a timely manner. Medication management includes the review of adherence, potential interactions, and oversight of the patient’s self-management.

🗸 Medication management

🗸 Community/social services ordered

🗸 A description of how outside services/agencies are directed/coordinated

🗸 Schedule for periodic review and, where appropriate, revision of the care plan Resources and Support. An inventory of resources and support are provided to the patient.