Seamless Transitional Care Management
Hoss-Kick's Transitional Care Management (TCM) provides critical support during post-discharge transitions to reduce readmissions and ER visits, ensuring smooth continuity of care from hospital to home.
The Critical Transition Period
The period immediately following hospital discharge is one of the most vulnerable times for patients. Without proper support, patients face high risks of readmission, medication errors, and complications that could have been prevented.
Without TCM Support:
- High readmission rates within 30 days
- Medication errors and confusion
- Missed follow-up appointments
- Emergency department visits
With Hoss-Kick TCM:
- Reduced readmissions and ER visits
- Proper medication management
- Coordinated follow-up care
- Smooth care transitions
TCM Care Process
Comprehensive support from hospital discharge through successful home transition
Discharge Planning
Coordinate with hospital staff to understand patient's condition, medications, and care requirements for smooth transition.
Key Activities:
- Review discharge summary
- Medication reconciliation
- Care plan development
- Patient education preparation
Initial Contact
Make contact with patient within 24-48 hours of discharge to assess immediate needs and address concerns.
Key Activities:
- Patient wellness check
- Medication review
- Symptom assessment
- Urgent needs identification
Care Coordination
Coordinate follow-up appointments, ensure medication compliance, and monitor for complications or concerns.
Key Activities:
- Schedule follow-up appointments
- Medication adherence support
- Symptom monitoring
- Care team communication
Stabilization
Continue monitoring and support until patient is stable and successfully transitioned to routine care.
Key Activities:
- Regular check-ins
- Progress monitoring
- Care plan adjustments
- Transition to routine care
TCM Benefits
Proven outcomes that benefit patients, providers, and healthcare systems
Reduce Readmissions
Significantly lower 30-day readmission rates through proactive post-discharge support
Prevent ER Visits
Early identification and intervention prevent unnecessary emergency department visits
Improve Patient Satisfaction
Patients feel supported and confident during vulnerable transition period
Faster Recovery
Proper support and monitoring lead to faster, more complete recovery at home
Better Medication Adherence
Medication reconciliation and support improve patient compliance and safety
24/7 Support Access
Patients have access to clinical support when questions or concerns arise
Start TCM Services Today
Begin offering Transitional Care Management to support your patients during critical post-discharge periods. Reduce readmissions and improve outcomes with comprehensive transition support.