CLICK HERE for latest COVID information.

Transitional Care Management Program

Professionally reviewed by Samantha K. Summers, MSN, RN, CRNP, FNP, CCRN, Manager, Transitional Care Management Program, on 05/31/2022.

Good Shepherd Rehabilitation Network’s Transitional Care Management (TCM) Program makes your return home from the hospital as easy and stress-free as possible.

During this transition, we understand it can be difficult to manage multiple health-care providers, appointments and medications.

Our dedicated TCM provider will help you manage these details so you can focus on your recovery, prevent a recurrence/readmission and get back to the things you enjoy.

How Does Transitional Care Management Work?

Transitional Care Management (TCM) is a 30-day program that begins with a meeting with your TCM provider while you are in the hospital. If you decide to register for the program, you can do so during that visit.

Within two days of discharge, the TCM provider will call to check on your condition and arrange an in-home or telehealth visit within 7 to 14 days. Be assured that we are taking all precautions possible to protect you from COVID-19 during in-home visits, including daily staff wellness screenings, masking, hand washing and sanitation procedures.

During this visit, the TCM provider will:

  • Evaluate how you have been feeling since discharge
  • Perform a physical exam (performed only during in-home exams)
  • Review your medications and care plan
  • Coordinate any remaining tests and/or treatments
  • Provide education
  • Connect you to needed community resources
  • Evaluate your home safety
  • Arrange follow-up phone calls

Throughout the process, the TCM provider will work with your primary care physician and your Good Shepherd Physician Group doctors to ensure coordinated care.

How Much Does Transitional Care Management Cost?

Transitional Care Management services are covered through your insurance.

Samantha K. Summers, MSN, RN, CRNP, FNP, CCRN

Samantha K. Summers, MSN, RN, CRNP, FNP, CCRN, is a nurse practitioner with the Good Shepherd Physician Group. Summers leads Good Shepherd’s Transitional Care Management Program, which helps patients transfer home successfully following inpatient rehabilitation.

Contact Us To Get Started Today

To learn more about Good Shepherd Rehabilitation Network’s Transitional Care Management (TCM) Program, call 1-888-44-REHAB (73422) or fill out the form below.

  • This field is for validation purposes and should be left unchanged.