Transitional Care Management (TCM)

When patients move from one care setting to another – for example, getting discharged from the hospital back home – they enter a high-risk period. Medications change, follow-up appointments are needed, and complications or confusion can easily arise in the first days and weeks. Transitional Care Management (TCM) is our solution to ensure patients successfully make that transition after an acute care stay, avoiding preventable readmissions and helping them recover safely.

Brilliant Care’s TCM service is a turnkey post-discharge care program modeled on Medicare’s TCM guidelines. We take a comprehensive approach to this critical 30-day window after discharge:

Key Benefits of Our TCM Program

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Patient connect Rate

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TCM visit scheduling rate

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TCM completion
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Reduction in 30-day readmission

Results and Metrics

Our TCM program has a proven track record. We’re proud to share that our approach yields patient connect rate >90%, a TCM visit scheduling rate of >80% and TCM completion rate of >70% within the timeline. More importantly, our clients have seen a 34% reduction in 30-day readmissions among patients managed with our transitional care service. This aligns with broader evidence that structured post-discharge programs drastically cut readmissions. In post-service surveys, patients’ satisfaction ratings average 9.5 out of 10, reflecting the personal touch and peace of mind we provide during what can be a scary period for patients.

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Medication Reconciliation

One of the first tasks is to review the patient’s discharge medications against what they were on before. Our clinicians perform a thorough medication reconciliation, identifying any discrepancies, explaining new meds to the patient, and ensuring they understand what to take and what to stop. If there’s any confusion or potential interaction, we coordinate with the discharging hospital or the primary care physician to clarify. Proper med management alone dramatically lowers readmission risk.

Follow-up Appointment Scheduling

We schedule the patient’s follow-up visit with their provider (PCP), ideally within 7 days of discharge (or 14 days for lower complexity cases) per best practices. If the patient needs labs or diagnostic appointments, we highlight those. Our team handles the logistics – calling the office, finding a convenient time, so nothing falls through the cracks. This addresses a common pitfall: without help, many patients fail to see their doctor promptly after a hospital stay.

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Individualized Support Plan

We discuss the patient’s recovery plan as per their discharge instructions: wound care, diet changes, activity restrictions, etc. We make sure they know the warning signs to watch for. We provide education in plain language to boost their confidence in managing at home.

Access to a Nurse

During this transition period, patients often have questions (“Is this symptom normal?”, “How do I use this new inhaler?”). We ensure they have direct access for any questions or concerns. We encourage them to call first rather than letting uncertainty grow – it’s always better to address issues early.

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Longitudinal Care

We don’t just call once and forget. For patients who qualify, we recommend, and enroll in our Chronic Disease Management program for ongoing care (length and outreach frequency based on their condition severity). This consistent engagement in those critical days and weeks post-discharge makes sure patients are educated, supported, and have what they need to stay on track.

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ADT Notifications & Patient Outreach

We work with you (and your hospital partners if applicable) to know when your patients are hospitalized and discharged. As soon as we receive an alert that a patient was discharged (or if we get a referral from your office), our team springs into action. We contact the patient within 1-2 days post-discharge to check on them. This timely outreach is vital; even the best hospitals report difficulties in ensuring follow-up calls happen within the recommended 48 hours, due to short time frames and limited staff. We fill that gap reliably.

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Coordination with Providers

We act as a bridge between the hospital and the outpatient provider. After our initial contact, we send the PCP or clinic a summary of the discharge further reducing provider burden.

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Transitional Care Management with Brilliant Care removes the common obstacles: difficulty reaching patients, lack of staff time to chase down discharges, uncertainty if patients followed instructions at home. We handle all that with a dedicated team that’s adept at post-acute care. And if you’re participating in value-based contracts or Medicare Advantage, reducing readmissions and improving post-discharge continuity will directly improve your performance metrics and potential shared savings.

In summary, our TCM service “bridges the gap” between hospital and home. By expanding the exceptional care from the hospital or exam room into the home setting, we enable access that transforms insights into outcomes – meaning the discharge plan (insight) actually gets executed and leads to healing (outcomes). Let us handle those critical transitions so your patients recover safely, and your organization reaps the benefits of fewer complications and happier patients.

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