Transitional Care Management (TCM)

Transitional Care Management (TCM)

Staying in the hospital can be overwhelming and scary. Returning home should not be. TCM is a service that makes you or your loved one’s return home a safe, positive experience.

What is TCM?

Transitional Care Management is patient-centered care provided to patients as they transition from the hospital to their homes. We aim to ensure you have everything you need to be successful and safe at home. It may include a one-time home visit after ER or Med Surg admissions to review discharge instructions, medications, and follow-up appointments. It may include home lab work and INR maintenance. Your visit is communicated with your provider to help prevent readmission to the hospital. 

Who Qualifies for TCM?

Any patient with a primary care provider at Cumberland Healthcare clinics and who has been hospitalized as an inpatient or in a Medicare Swing bed/TCU at any facility is qualified for TCM.

The Benefits of TCM

If you have any chronic conditions, such as COPD, congestive heart failure, or diabetes TCM can provide you with information about these and show you ways to improve your health at home. We can help sort out medications to be sure that you are taking the correct doses at the correct times, and, best of all, we can decrease your chances of being readmitted to the hospital. Your visit 

What Does TCM Include?

While you are in the hospital, a TCM nurse will work with you and your family to help meet everyone’s needs t home so you will be as successful as possible when you are discharged. You will also be provided with the option of having a TCM nurse come to your home for a home visit or an in-depth phone call to ensure you have everything you require to thrive. Your primary care provider will see you within one-to-two weeks for a focused follow-up, and you will receive ongoing education and appropriate community referrals as needed.

Who Pays for TCM Services?

You, as the patient, will never see a bill for transitional care, regardless of insurance coverage. Transitional care is covered by Medicare and many other insurances. There are criteria that need to be met in order to bill for this service. If this service is not covered by your insurance, TCM will be provided to you at no cost.

Your TCM Coordinator

Tammy Becker, RN, BSN. She can be reached at 715-822-7412 or