Transitions in Care

Houston Methodist Physicians’ Alliance for Quality’s Transitional Care Management (TCM) services aim to improve care coordination post-hospitalization and provide incentives to ensure that patients are seen in a physician’s office after discharge, so as to reduce the risk of readmission. TCM involves a single in-person visit with a patient within a specified period of time, along with other services (not in person) performed by a physician or other qualified health care professionals and/or licensed staff under a physician’s direction.

Additional services may include the following:

  • Communication with the patient, caregiver(s) and other home health agencies or community services
  • Education for the patient and/or caregiver(s) to support daily living activities
  • Reviewing discharge information, along with assessments and support regarding medications and adherence
  • Follow-up regarding additional tests and treatments
  • Follow-up with new health care providers
  • Identification of referrals and community and health resources
  • Facilitating access to care and services

More Information About TCM:

Transitions in Care Management Information Packet

Transitions in Care Management Codes

Transitions in Care Management Example

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