How Transitional Care Management Supports Recovery at Home
Leaving the hospital is a major step—but for many patients, it’s also when care can feel the most overwhelming. Medication changes, new diagnoses, follow-up appointments, and unanswered questions can make recovery stressful and confusing.
At New Heights Health and Wellness, our Transitional Care Management (TCM) services are designed to bridge the gap between hospital and home, helping patients in Missouri and Kansas recover safely, confidently, and with continuous medical support.
What Is Transitional Care Management (TCM)?
Transitional Care Management is a Medicare-covered service that provides structured medical support during the critical 30 days after discharge from a hospital or skilled nursing facility.
The goal of TCM is to:
- Reduce hospital readmissions
- Prevent complications
- Improve medication safety
- Ensure timely follow-up care
- Support a smoother recovery at home
TCM goes beyond a single follow-up visit. It includes ongoing provider oversight, care coordination, and patient education during a particularly vulnerable period.
Who Is Transitional Care Management For?
TCM is ideal for patients who have recently been discharged from:
- A hospital
- A rehabilitation facility
- A skilled nursing facility
It is especially helpful for individuals who:
- Have multiple chronic conditions
- Experienced a recent hospitalization or procedure
- Were started on new medications
- Feel unsure about next steps in their care
- Need extra support to avoid returning to the hospital
Many Medicare patients qualify, and services may also be available through a hybrid model of insurance and private pay, depending on individual needs.
How Transitional Care Management Works at New Heights Health and Wellness
At New Heights, TCM is personalized, proactive, and provider-led—not rushed or transactional.
Our TCM process includes:
- Timely post-discharge contact within 48 hours to review your transition home and address immediate concerns
- Medication reconciliation to reduce errors, interactions, and confusion
- Care coordination with hospitals, specialists, pharmacies, home health agencies, and family members
- Ongoing provider support for 30 days, including check-ins and symptom monitoring
- Follow-up visit management to ensure appointments are scheduled and meaningful
Our approach focuses on prevention, education, and long-term stability—not just short-term recovery.
Conditions That Benefit from Transitional Care Management
TCM is especially beneficial for patients managing complex or chronic health conditions, including:
- High blood pressure and heart disease
- Diabetes
- Chronic kidney disease
- Liver disease (including MASLD/MASH)
- Digestive and gut health conditions
- Chronic respiratory conditions (COPD, asthma)
- Post-surgical recovery
- Frequent hospitalizations or ER visits
- Multiple medication changes
Patients with overlapping conditions often benefit most from consistent provider oversight during transitions of care.
Serving Patients Across Missouri and Kansas
New Heights Health and Wellness proudly provides Transitional Care Management services to patients throughout Missouri and Kansas, with a focus on compassionate, high-quality care during life’s most critical health transitions.
Whether you were recently hospitalized or are caring for a loved one, we’re here to help you move forward with confidence.
Ready to Get Support After Discharge?
If you or a loved one has recently been discharged from the hospital and needs help navigating the next steps, Transitional Care Management may be right for you.
👉 Schedule a consultation and let’s ensure your recovery continues safely—at home.
