Transitional Care Management in Fort Myers & Lehigh Acres
- Post-discharge follow-up
- Medication review
- Referral & appointment coordination
- Fort Myers & Lehigh Acres
What Is Transitional Care Management?
Transitional Care Management, often called TCM, is short-term follow-up care designed to help eligible patients transition from certain inpatient healthcare settings back into the community.
During the transition period, the primary care team may help review information from the hospital or facility, organize follow-up care, review medications, communicate with other providers, and address questions that arise after discharge.
TCM typically focuses on the first 30 days following a qualifying discharge.
TCM Reconnects Hospital Care With Primary Care
The First Days at Home Can Be Complicated
Understand Your Discharge Plan
Review Medication Changes
Organize Follow-Up Care
Know What Comes Next
What Transitional Care Management May Include
Hospital or Facility Record Review
Medication Reconciliation
Timely Primary Care Follow-Up
Specialist & Referral Coordination
Care Plan Review
Patient & Caregiver Communication
Who May Benefit From Transitional Care Management?
TCM may be appropriate for eligible patients returning to the community after certain qualifying inpatient healthcare stays.
Inpatient hospital discharge
Skilled nursing facility discharge
Skilled nursing facility discharge
Skilled nursing facility discharge
What Happens After You Leave the Hospital?
You Return Home or to the Community
Your Care Team Connects With You
Your Follow-Up Visit Is Scheduled
Your Care Is Coordinated
How Soon Should Follow-Up Happen After Discharge?
Timely follow-up is an important part of Transitional Care Management. If you recently returned home after a hospital or qualifying facility stay, contact PrimaryCareIM as soon as possible so our team can review the timing and next steps for your care.
Recently Discharged?
Understanding Your Medications After Discharge
- New prescriptions
- Different dosages
- Medications that were discontinued
- Temporary medications
- Questions about medications they were already taking
Medication Management
Learn how PrimaryCareIM supports ongoing medication review and treatment management.
Is Transitional Care Management the Same as Care Coordination?
Transitional Care Management
Care Coordination
Is TCM Just a Regular Hospital Follow-Up Visit?
Regular Follow-Up Visit
- Focus on symptoms after hospitalization
- Review of current treatment
- Single office visit
Transitional Care Management
- Communication after discharge
- Medication reconciliation
- Review of hospital or facility information
- Coordination of providers and services
- Management of the overall transition period
Transitional Care for Adults and Seniors
Adult Transitional Care
Senior Transitional Care
Helping Connect Hospital Care Back to Primary Care
Hospitals focus on stabilizing and treating immediate medical needs. Once you return home, your primary care team becomes an important part of what happens next.
PrimaryCareIM can help bring together:
- Discharge Records
- Medications
- Specialist Recommendations
- Testing
- Symptoms
- Follow-up Appointments
- Ongoing Health Conditions
Recently Discharged From the Hospital?
Does Medicare Cover Transitional Care Management?
Medicare Part B may cover Transitional Care Management services for eligible patients following a qualifying inpatient stay.
Deductible and coinsurance requirements may apply. Individual costs can vary based on coverage and the services received.
Not Sure Whether Your Discharge Qualifies?
Contact PrimaryCareIM and your insurance plan so your specific coverage and benefits can be verified.
Insurance Plans We Work With
PrimaryCareIM works with Medicare, many Medicare Advantage plans, and a range of major insurance providers.
Insurance networks and participation can vary by specific plan and location. Please contact our office or your insurance provider to confirm that PrimaryCareIM is in-network for your individual plan before scheduling.
Transitional Care Management in Fort Myers & Lehigh Acres
Fort Myers Office
Lehigh Acres Office
Care That Continues After Your Transition
Advanced Primary Care Management
Chronic Care Management
Remote Patient Monitoring
Transitional Care Management FAQs
What is Transitional Care Management?
Transitional Care Management (TCM) is short-term follow-up care that helps eligible patients move from certain inpatient healthcare settings back into the community. It may include reviewing discharge information, reconciling medications, coordinating follow-up care and answering questions during the transition period.
Who qualifies for Transitional Care Management?
TCM may be appropriate after a qualifying inpatient stay, such as an inpatient hospital, skilled nursing facility or certain inpatient rehabilitation discharges. Eligibility depends on the type of discharge and applicable program requirements, so our team can help review your individual situation.
How soon should I see my primary care provider after leaving the hospital?
Timely follow-up is an important part of the transition. Contact PrimaryCareIM as soon as possible after discharge so our team can review the timing and schedule an appropriate follow-up visit.
What should I bring to my post-hospital follow-up?
Bring your discharge paperwork and instructions, your discharge medication list, all medication bottles you currently take, any new prescriptions, and a list of your questions. A family member or caregiver is welcome to join you.
Will my medications be reviewed?
Yes. Medication review is a core part of Transitional Care Management. Your provider can compare your discharge medication list with what you are currently taking and clarify new, changed or discontinued medications when appropriate.
Is Transitional Care Management only for seniors?
No. TCM may be appropriate for eligible adults of any age following a qualifying inpatient discharge. Older adults often need additional coordination, but the service is not limited to seniors.
Does Medicare cover TCM?
Medicare Part B may cover Transitional Care Management for eligible patients after a qualifying inpatient stay. Deductible and coinsurance may apply, and costs can vary. Please check with our office and your insurance plan to confirm your specific coverage.
What if I don't know whether my hospital stay qualifies?
That’s common. Call PrimaryCareIM after your discharge and our team can review your discharge details and help determine the appropriate follow-up, whether or not it falls under Transitional Care Management.