Transitional Care Management Simplified

Smart Care 360 enables care plan development with monthly communication to
patients and other treating health professionals for patients with at least 1 chronic condition. Principal Care Management (PCM) services are rendered to patients remotely and provide patients with 24/7 access to a clinician, and a monthly care plan and updates.

The Entire Patient Journey

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Transitional Care

Stay Ahead of your Health

Smart Care 360’s mobile app allows you to stream vitals utilizing FDA approved bluetooth devices. User your mobile device to access health care services remotely and manage your health care.

Patient-Centered Care Management

Patient first, patient centered care is our priority. We have certain staff to patient ratios so that patients receive the time and care they need each month to improve their health & wellness and prevent chronic episodes or hospital admissions.
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Built-in Patient Education & Gamification Compliance Tools

Delivering Happy HealthCARE!

Why Transitional Care Matters Most After Discharge

TCM supports patients during the crucial first month after discharge by ensuring follow-ups, preventing complications, and guiding recovery with structured care.

How TCM Improves Communication Between Providers and Patients

TCM strengthens provider-patient communication through timely check-ins and coordinated care, reducing confusion and supporting recovery.

From Hospital to Home: How TCM Supports a Seamless Transition

TCM eases the move from hospital to home by coordinating care, reviewing medications, and guiding follow-up steps for a smooth recovery.

The Link Between TCM and Better Chronic Disease Management

TCM provides ongoing support and regular follow-ups for chronic patients, helping them manage conditions effectively and avoid complications.

Why TCM is a Win-Win for Patients and Providers

TCM benefits both patients and providers by reducing readmissions, improving satisfaction, and ensuring smoother care transitions.

Key Components of Effective Transitional Care Management

Effective TCM includes timely outreach, medication reviews, follow-ups, and patient education to ensure a safe, coordinated recovery.

Benefits

For Practices

For Patients

What is Transitional Care Management and Why Does It Matter?

Transitional Care Management (TCM) supports patients after hospital discharge with timely follow-ups, bridging care gaps and helping prevent readmissions for a safer, smoother recovery...

Benefits of Transitional Care Management for Patients

TCM helps patients avoid complications after leaving the hospital by providing structured follow-up care. From medication reviews to appointment scheduling, it offers peace of mind and smoother transitions toward recovery..

How TCM Helps Providers Deliver Continuity of Care

TCM gives healthcare teams the tools to stay involved in a patient’s recovery journey. It enables proactive outreach, better communication, and a consistent care plan, improving both clinical outcomes and patient satisfaction..

Reducing Hospital Readmissions with Transitional Care Management

TCM helps reduce hospital readmissions by supporting patients with clear instructions, medication management, and timely follow-up care after discharge..

The Role of Care Coordination in Transitional Care Management

Effective care coordination is at the heart of TCM. By connecting physicians, patients, and support services, TCM helps create a clear recovery path, reducing confusion and promoting better health outcomes..

Who Can Benefit from Transitional Care Management?

TCM is ideal for patients with chronic conditions, recent surgeries, or complex needs, offering crucial support during the recovery period after hospital discharge..

Schedule a demo now to analyze how Smart Care 360 will increase efficiency and revenue generated within your practice.

(FAQs) – Transitional Care Management

Transitional Care Management (TCM) is a Medicare-supported service that helps patients safely transition from hospital or facility care back to their home. It focuses on preventing readmissions and ensuring proper follow-up care.

TCM services are available to patients who have been discharged from a hospital, skilled nursing facility, or other qualifying care setting and require medical follow-up within a specific timeframe.

MRG Health provides coordinated TCM services that include follow-up calls, medication reconciliation, appointment scheduling, and care plan reviews to ensure patients receive timely, appropriate care

TCM helps reduce hospital readmissions, improves communication between providers and patients, and ensures that individuals continue to receive the care they need during a vulnerable recovery period.

Our TCM program includes care coordination, medication review, symptom monitoring, follow-up visits, and connection to additional healthcare or community resources.

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MRG Health provides a complete solution that helps improve patient outcomes while increasing practice revenue and cost.