Transitional Care Management


Immunizations care

What is Transitional Care Management (TCM)?

For individuals transitioning from an in-patient facility back into the community, TCM helps patients to feel comfortable at home and regain their independence. These services seamlessly pick up from discharge with no gap in services to the patient.

 Common In-Patient Facilities  Common Community Settings
  •  Inpatient Acute Care Hospital
  • Inpatient Psychiatric Hospital
  • Long-Term Care Hospital
  • Skilled Nursing Facility
  • Inpatient Rehabilitation Facility
  • Hospital outpatient observation or partial hospitalization
  • Partial hospitalization at a Community Mental Health Center
  • Home
  • Domiciliary
  • Rest home
  • Assisted living facility


Why choose Transitional Care Management (TCM) with 1st Care Management?

TCM participation has proven to help reduce hospitalizations within the home-bound population by incorporating a home visit shortly after discharge.

What is included in Transitional Care Management?

  • Initial contact
    • Phone
    • Email
    • Face-to-Face


  • Remote Services
    • Communication between patient’s care team
    • Education on self-management, independent living and activities of daily living
    • Assessment of medication management & treatment follow through
    • Identification of community and health resources to benefit the patient
    • Assessing care and services needed by the patient


  • Face-to-Face Visit
    • Completed by Nurse Practitioners
    • Supervised by qualified Physicians


1st Care Management looks forward to providing you with quality primary care services.  

Our ability to correctly diagnose and understand a disease’s origins is a the first step to becoming a healthier you!