Transitions of care
Help with the next steps after discharge.
Transitional care management supports the move back to the community after a qualifying hospital or facility stay. It connects discharge instructions, medicines, and follow-up during the first 30 days.
Ask your care teamWhat care looks like
Understand the support.
Make sense of what changed
Review the discharge information and questions about your medication list with the care team.
Connect with your practice
Help coordinate the follow-up visit and share concerns with the clinician managing your transition.
Keep the next steps clear
Discuss appointments, referrals, and other needs as you settle back into your routine.
Before you begin
A clear first step.
Let your practice know
Tell your practice about the discharge so it can arrange timely contact and follow-up.
Have discharge papers ready
Keep the instructions, medication list, and questions available for the care team.
Confirm the follow-up plan
Ask when to see your clinician and whom to contact with concerns before the appointment.
Questions are welcome
A little more clarity.
For more about the program, read Medicare’s transitional care management guide.
Does this replace my follow-up appointment?
No. A timely visit with the clinician is an important part of transitional care. Your practice confirms when that appointment should happen.
What if my medication instructions do not match?
Contact your treating practice or care team for clarification. A pharmacist can help review the information and bring the question to the responsible clinician.
What happens after the first month?
Your practice reviews what ongoing support you need. Another care program may be discussed if it is appropriate and you meet its requirements.
Talk it through with us.
If your clinic gave you a direct care-team number, use that number. Otherwise, call 1 (844) 248-6724.