Discharging home does not mean that your healthcare needs are over. Community Transition Nurse provides Transitional Care Management (TCM), or short-term episodic care for patients discharging from a healthcare facility (Hospital, Rehab, Nursing Home, Psych Facility) and returning to their home, assisted living, or community setting.
Transitional Care Management is an important part of the patient’s discharge plan when leaving the facility for continuity of care and providing immediate access to a healthcare provider for medical decision-making. Transitional care helps with the continuation and continuity of care from the facility to your home. Our program includes and not limited to obtaining and review of medication/prescriptions, diagnostics, lab tests to be monitored and treated, coordination of care with other health care providers such as your Primary Care (PCP), Home Health Agency, Home Medical Equipment and Pharmacy. Also, we establish or re-establish referrals for community resources identified upon assessment. TCM services provided upon facility discharge and for the next 29 days after leaving the facility.