• Burlingame, CA
  • Office Hours: 8:30am - 5:00pm PST

Transitional Care Management (TCM)

Just Left the Hospital?
We've Got You.

The days right after a hospital stay are the most vulnerable — and the most important. Our TCM program makes sure you land safely at home with the support, follow-up, and guidance you need to fully recover.

What We Do After You're Discharged

TCM begins the moment you leave the hospital. Here's what happens in the days and weeks that follow:

  • 1
    Contact within 2 business days of discharge Your care coordinator reaches out by phone to check in on how you're feeling, answer questions, and confirm you have everything you need at home.
  • 2
    Medication review and reconciliation We go through every medication you were given at the hospital — making sure you understand what each one is for, when to take it, and whether there are any conflicts with what you were already taking.
  • 3
    Follow-up visit within 7–14 days A face-to-face visit with your physician or care team is scheduled within 7 days for high-risk patients and 14 days for moderate-complexity cases — so nothing falls through the cracks.
  • 4
    Care coordination and specialist referrals We contact any specialists you need to see, coordinate test results, and make sure everyone on your care team is on the same page.
  • 5
    Family and caregiver support We make sure your family or caregiver is informed, prepared, and knows how to reach us if something changes — because recovery is a team effort.

What You Get with TCM

  • Immediate outreach after leaving the hospital or skilled nursing facility
  • Medication review so you know exactly what to take and when
  • Scheduled follow-up visit within 7–14 days
  • Coordination with all your doctors, specialists, and care facilities
  • Support for your family or caregiver throughout your recovery
  • Covered by Medicare — no extra cost for eligible patients

Why It Matters

Hospital Readmissions Are Often Preventable

1 in 5 Medicare patients is readmitted to the hospital within 30 days of discharge. Most of those readmissions are preventable with the right follow-up care — medication guidance, a check-in call, a timely follow-up visit.

Health Connect MSO's TCM program exists to close that gap. We make sure your transition from hospital to home is smooth, supported, and safe.

20% of patients readmitted within 30 days
7–14 days to your first follow-up visit

Covered by Medicare

TCM is covered under Medicare Part B for patients discharged from hospitals, skilled nursing facilities, or inpatient rehab. Most patients have little to no out-of-pocket cost.