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What Does Transitional Care Management Involve?

What Does Transitional Care Management Involve?

If you or a loved one has ever experienced a life-altering event like a heart attack or stroke, or major surgery that required a hospital or other type of inpatient care stay, you know that the prospect of finally returning home is both a huge relief and a source of stress all at the same time. The thought of getting back to familiar surroundings and your old routines is exciting, but you wonder if it’s really possible. 

After all, there are all these new follow-up services you need to schedule, and the medication list alone can be confusing. You don’t want to burden your family with all these new responsibilities, but you also don’t want to land back in the hospital.

Don’t panic, say the caring providers at Generations Family Practice in Cary, North Carolina.  A comprehensive personalized plan called transitional care management is available to help you get the follow-up care you need. In this blog, we’ll unpack what transitional care management is and how it can get you back to feeling more like yourself again.

Transitional care management explained

Transitional care management, or TCM, is a lot like having your own medical personal assistant who not only understands the terminology, but can also weed through things like your discharge list of medications and compare them against the medicines you may already be taking. Remarkably, 30% of patients returning home from a hospital or inpatient care setting have at least one discrepancy in this area alone.

Specifically, transitional care management pulls together all the medical details needed for you to heal and recover and puts it into one coordinated services plan so you or your family or caregiver don’t have to take it on and figure it out by yourself. 

Although each TCM varies from patient to patient depending on the condition being treated, generally transitional care management plans cover about the first 30 days after the release from a hospital, nursing home, or inpatient care facility for both physical and mental health coordinated care.

Enables you to focus on healing

The big plus for transitional care management is that it allows patients to focus on healing and their families or caregivers to focus on providing additional support in the recovery process, instead of expecting them to pick up the burden of coordinating medical services that they may not completely understand.

Helps avoid readmissions

Essentially, transitional care management acknowledges that the patient, their family, or their caregiver isn’t immediately going to become an expert on all medical topics and processes just because it’s time to transition from a hospital setting to home. 

This simple premise and the opportunity that transitional care management offers can avoid needless issues that send them back to the hospital. Unfortunately, an estimated 20% of all patients experience a preventable health problem within three weeks of returning home. 

Includes a variety of personalized coordinated care

Another important part of transitional care management is that it includes the coordination of a wide spectrum of care that’s often part of the recovery process when you return home.

Since no two people are the same, any medical issues like strokes, injuries, or things like a hip transplant aren’t identical either. Transitional care management takes that into consideration by providing plans that are uniquely dialed in for each patient with the goal to get and maintain exceptional physical and mental health.


Examples of the type of services that may be included in transitional care management plans include:

Physical or occupational therapy

Addressing mobility issues may often be part of TCM plans. Here at Generations Family Practice we offer physical rehabilitation therapy, which can be complimented by acupuncture or massage to enhance mobility and promote healing. 

Medication or pain management

Our highly skilled medical team offers a diverse array of pain management options, including holistic pain-relieving solutions such as joint injections and osteopathic manipulation, which complement massage and physical therapy.

Smoking cessation

Quitting smoking for good may be the hardest task many people encounter. The good news is you don’t have it go it alone. Here at Generations Family Practice we offer highly effective smoking cessation programs and treatments to help.

Chronic care management

Sometimes transitional care management acts as a springboard for learning how to live with a medical condition for the rest of your life. Our chronic care management services can extend well after the typical care management plan ends. Our goal is to lower your risk of developing complications and mitigate any unpleasant symptoms while raising your quality of life.


To learn more about transitional care management, make an appointment at Generations Family Practice today. Book an appointment online or call us at 919-852-3999.

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