Transitional Care Management (TCM)

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Transitional Care Management (TCM) is provided when a patient transitions from one care setting to another care setting, such as from a hospital to a personal residence or assisted living. It is based on a comprehensive care plan and includes logistical arrangements and the education of patient and family, as well as coordination among the health professionals involved in the transition. TCM is designed to ensure coordination and continuity of care.

  NavCare Nurse's Testimonial

“I called the patient the day after hospital discharge. As soon as I asked how the patient was doing, he stated he could not get his heart drug filled because the insurance company had denied it and he could not afford to pay out of pocket. This particular drug treats life-threatening arrhythmias and is not something a patient can just skip or do without.

After ascertaining the patient had enough of the drug on hand for the next two days, I reached out to the pharmacy to try to find a solution ... The patient was going to wait until next week to talk to [his doctor] about it ... The patient was very reassured and thankful that we are going to notify [his doctor] and call him back tomorrow. We worked with the patient’s physician to change the medication so that insurance would cover it. The patient was able to fill his medication the next day and not miss a dose.”

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