Transitional Care Management
TCM refers to the coordination and continuity of health care during a movement from one healthcare setting to another. That is called a Transition of Care, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Family Health Center aims to deliver the best possible care transition, we can't do this along. That is why we ask that our patients make contact with our clinic the first day they are discharged from a healthcare setting. We will then schedule an appointment for follow-up with a provider within 7 days of initial discharge. At the Transition of Care Visit the provider will review all healthcare setting discharge paperwork, review medications, review changes in diagnoses, coordinate any care needed with other healthcare providers and make a plan to manage new or acute problems.