Transitional Care Management Program

Good Shepherd Rehabilitation’s Transitional Care Management (TCM) Program makes your return home from the hospital as stress-free as possible.

During this transition, we know it can be difficult for you or your loved ones to manage multiple healthcare providers, appointments and medications.

To assist, Good Shepherd offers a dedicated TCM provider, who is a licensed nurse practitioner. The TCM provider helps you manage these details so you can focus on your recovery, prevent a recurrence/readmission and get back to the things you enjoy.

How Does Transitional Care Management Work?

TCM is a 30-day program that begins with a meeting with your TCM provider while you are in the hospital. If you decide to register for the program, you can do so during that visit.

Within two days of discharge, the TCM provider will call to check on your condition and arrange an in-home or telehealth visit within seven to 14 days.

During this visit, the TCM provider will:

• Evaluate how you have been feeling since discharge
• Perform a physical exam (performed only during in-home exams)
• Review your medications and care plan
• Coordinate any remaining tests and/or treatments
• Provide education
• Connect you to needed community resources
• Evaluate your home safety
• Arrange follow-up phone calls

Throughout the process, Good Shepherd’s TCM provider will work with your primary care physician and your Good Shepherd Physician Group doctors to ensure coordinated care.

How Much Does Transitional Care Management Cost?

Transitional Care Management services are covered through your insurance.