Doctor with clipboard discussing care management with a lady.

Going home from the hospital or nursing home does not mean that a loved one’s healthcare needs are over. The transition period between the time of discharge from the hospital and when routine care is reestablished can be confusing for both the loved one and their caregivers. This is where transitional care management (TCM) comes in.

What is transitional care management?

TCM bridges the gap between an inpatient stay and care in the home. The extra support can help the person adjust to new medication, care routines, and manage barriers to self-management.  When people over the age of 65 are going home from the hospital or nursing home, they should call their doctors immediately and visit their doctors within 14 days.

TCM has been shown to lower mortality rates by 38%. This according to a study published in the Journal of the American Medical Association. Additionally, TCM saves Medicare 10% in health care spending.

It’s common to think that people discharged to the home must be ready to manage their health conditions independently. Dementia, heart disease, COPD, diabetes, and other chronic conditions can often be managed in the home setting and transitional care management can help ensure continuity of care during the transition period.

A simple phone call and doctor visit can help retirees prevent rehospitalization and possibly save their lives.  


Bindman A, Cox D. Changes in health care costs and mortality associated with transitional care management.  JAMA Intern Med. 2018: 178 (9): 1165-1171.

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