Transitional Care Management (TCM)

The ReliantHealth process to getting a specialist referral:

step1
Your Primary Care Visit
Your journey begins with a comprehensive assessment by our primary care providers. They will evaluate your symptoms and medical history to determine the appropriate course of action.
step2
Specialist Approval
Your journey begins with a comprehensive assessment by our primary care providers. They will evaluate your symptoms and medical history to determine the appropriate course of action.
step3
Consultation with Specialist
Your journey begins with a comprehensive assessment by our primary care providers. They will evaluate your symptoms and medical history to determine the appropriate course of action.
step4
Follow-up and Coordination
Your journey begins with a comprehensive assessment by our primary care providers. They will evaluate your symptoms and medical history to determine the appropriate course of action.
transitional care
Transitional care management is a comprehensive approach that bridges the gap between acute care (such as hospitalization) and post-acute care (including outpatient settings, skilled nursing facilities, and home care). Its primary goal is to ensure a smooth transition for patients, enhance continuity of care, and prevent adverse events during this critical phase.
How ReliantHealth guarantees an appointment with a provider within 72 hours of discharge

1. Patient Contact Within 48 Hours

  • After hospital discharge, the the ReliantHealth primary care team intiates contact within 48 hours.
  • This early communication reconnects the patient with us, establishes rapport, and identifies any immediate needs.
  • the ReliantHealth primary care team can see new patients, patients without a PCP, or patients who have a PCP but just need to see a doctor for refills while they wait for their regular PCP appointment.

2. Scheduling an Office Visit

  • Within 2-7 days after discharge, we schedule an office visit with you.
  • During this visit, our primary care team reviews the care plan, assesses progress, and addresses concerns.

3. Care Plan Discussion

  • Our doctor engages in a detailed discussion with the patient and caregivers.
  • Topics covered include medication management, follow-up tests, lifestyle adjustments, and social support.

4. Reducing Readmissions

  • TCM aims to prevent hospital readmissions by ensuring timely follow-up.
  • Effective communication among healthcare providers and adherence to protocols play a crucial role.
Hospitals, Case Managers, Discharge Planners and Patients:
Call Our TCM Team at (725) 735-5120

Benefits and Outcomes:

Find Us On Careport under “Reliant Clinic”

1. Improved Patient Satisfaction

  • Patients who receive TCM report higher satisfaction due to personalized attention, clear instructions, and coordinated care.
  • Feeling supported during the transition enhances their overall experience.

2. Reduced Healthcare Costs

  • ReliantHealth’s TCM modality reduces unnecessary hospital readmissions, emergency department visits, and prolonged stays.
  • Cost savings result from fewer complications and better adherence to care plans.

3. Enhanced Continuity of Care

  • TCM ensures that patients continue receiving appropriate care after leaving the hospital.
  • It minimizes disruptions and prevents gaps in follow-up.

4. Fewer Adverse Events

  • By addressing medication reconciliation, monitoring symptoms, and managing chronic conditions, TCM reduces adverse events.
  • Early detection of complications leads to timely interventions.

5. Better Medication Management

  • TCM emphasizes medication reconciliation, adherence, and education.
  • Patients receive clear instructions on when and how to take medications.

6. Effective Care Coordination

  • TCM involves collaboration among PCPs, specialists, nurses, and other healthcare professionals.
  • Coordinated efforts lead to smoother transitions.

7. Reduced Length of Stay (LOS)

  • When patients transition seamlessly, LOS decreases.
  • Efficient discharge planning and follow-up contribute to shorter hospital stays.

8. Improved Outcomes in Skilled Nursing Facilities (SNFs)

  • TCM benefits SNFs by ensuring that patients arrive with accurate information and care plans.
  • SNF staff can focus on rehabilitation and recovery.

9. Enhanced Home Care Transitions

  • Patients transitioning from SNFs to home receive personalized support.
  • Education on self-management and caregiver involvement improves outcomes.

10. Healthcare System Impact

  • TCM reduces the burden on hospitals, freeing up resources for acute cases.
  • It aligns with value-based care models and population health management.

The ReliantHealth transitional care team have extensive experience with managing transitions from the hospital and other facilities, and work with payers, portals and patients to ensure a quick post-discharge visit with our doctors.