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Transition Care Management

Transition Care Management (TCM)
Turn Discharges Into Results - We Follow the Patients Home

At Advanced Life MSO, we support Medicare patients during the critical 30-day period after hospital or skilled nursing facility discharge. Our TCM program ensures timely follow-ups, reduces avoidable readmissions, and provides patients with the support they need to recover safely at home.

What We Do

Transition Care Management (TCM) is a structured, 30-day care program designed to support patients after discharge from a hospital or skilled nursing facility. It ensures continuity of care, early intervention, and improved health outcomes.

At Advanced Life MSO, we deliver TCM as a comprehensive, field-based service bringing the medical team to the patient and integrating multiple layers of care:

  • In-Home Medical Oversight: Our providers visit patients at home or via telehealth to review medications, assess recovery, and coordinate ongoing needs.
  • Remote Patient Monitoring (RPM): Vital signs and health data are tracked in real time to catch potential issues before they become serious.
  • Chronic Care Management (CCM): For patients with chronic conditions, we provide coordinated care planning and ongoing clinical support.
  • Care Navigation & Follow-Ups: We manage communication, follow-up scheduling, and continuity of care throughout the 30-day transition period.

Why It Matters

  • Reduces hospital readmissions
  • Improves patient safety and outcomes
  • Enhances coordination across care teams
  • Supports smooth transitions from facility to home
  • Builds trust and long-term engagement with patients

Who We Serve

  • Skilled Nursing Facilities (SNFs)
  • Hospitals and Discharge Teams
  • Primary Care Groups
  • Home Health Agencies
  • Medicare beneficiaries transitioning home

Get Started

Let Advanced Life MSO manage your post-discharge care transitions with professionalism, compassion, and measurable results.