TCM with MRG Health

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

Calculate Your Future Profits With MRG

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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.
kit1-MRG Health

Built-in Patient Education & Gamification Compliance Tools

Delivering Happy HealthCARE!

Who Qualifies for TCM?

TCM is ideal for: recent hospital/surgery patients, those with chronic conditions (diabetes, COPD, heart failure), Medicare beneficiaries (fully covered), and high-risk seniors needing post-discharge support. We verify eligibility before you leave the hospital.

Your First 48 Hours

Within two days of discharge, your dedicated care coordinator will call to review medications (comparing hospital orders with your current prescriptions), identify urgent symptoms needing immediate attention (like fever or severe pain), and provide optional caregiver training. This critical check-in ensures a safe transition home.

The 7-Day Safety Check

Within 7 days of discharge, your provider will visit (in-office or at home) to check healing progress, adjust medications, order tests if needed, update your care plan, and help solve practical barriers like transportation or equipment needs.

30 Days of Support

Get weekly check-ins to track weight, blood sugar, and medications. We schedule specialist visits and provide urgent same-day support—ensuring safe recovery for 30 days post-discharge.

Peace of Mind Features

Our digital health tools include Bluetooth-enabled blood pressure monitoring and real-time symptom tracking with automatic clinician alerts. Designated family members can access your care plan through a secure portal, and we connect you to community resources like meal services and support groups for holistic recovery support.

No Surprise Bills

We handle all insurance verification upfront (including Medicare approval for TCM services), ensuring $0 copays for patients and guaranteed coverage. Our billing team manages any claim denials or appeals, so you never face unexpected costs.

Benefits
For Practices
For Patients

Care Coordinator

Your dedicated care coordinator serves as your main contact, managing all post-discharge needs and providing phone/text support for urgent questions throughout your recovery.

Medication Manager

Your dedicated pharmacist reviews all prescriptions to prevent dangerous interactions and provides clear, easy-to-follow medication schedules for safe recovery at home.

Primary Care Navigator

Your primary doctor oversees recovery, adjusts care plans as needed, and coordinates specialist referrals for seamless post-hospital care.

Home Health Specialist

A skilled professional visits your home to assess safety, provide wound care/rehab exercises, and train family caregivers for optimal recovery support.

Insurance Advocate

Your dedicated advocate verifies coverage, resolves claim issues, and explains costs in simple terms—ensuring no surprise bills during recovery.

Community Connector

Connects you with local resources like meal delivery, transportation, and condition-specific support groups for holistic recovery assistance.

Interested in learning more about what patients are eligible to participate and how TCM is relevant to your practice?

Smart Care 360-MRG Health

New Technologies That Deliver.

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

LUCAS KRAUSE
PhD MSC
 IT Infrastructure & Architecture 
Lucas is a 20+ year experience enterprise Cloud Solutions Architect who has worked with fortune 100 companies and is competent in the following: Enterprise API Gateways – AWS | Azure | Salesforce | Mulesoft | Apigee | IBM Cloud | Anypoint | Cloud Data Warehouse – Snowflake | DBT | Cloudara | Airflow | Kubernetes | AWS | Looker | Prometheus | Full-Stack / Cloud Native – C# / Java / React / Angular / Golang / Python – Cloud DBs – Dynamo / Mysql / Postgres / MSSql / Oracle / Netezza
RENE HINOJOSA
MBA
Compliance & Regulatory 
Experienced Director of Strategic Development with a demonstrated history of spearheading initiatives throughout the healthcare system. Skilled in Physician Relations, Software Documentation, Healthcare Management, Healthcare, and Public Speaking. Strong program and project management professional with years of a proven track record that showcases a creative and proficient skill-set in problem solving.
TY UMOH
MD MBA
Investor Relations & Finance 
Ty has a bachelor’s degree in Accounting & Finance from the University of Houston and a Master’s degree in Economics and Corporate Finance from Rice University. Previously, Ty worked as a senior consultant at FTI Consulting, Inc., advising various stakeholders of troubled and distressed companies across a wide range of industries, including financial services, hospitality, gaming, commercial real estate, energy & oil field services, construction, infrastructure, and municipal-related assets. Additionally, my prior experience includes roles at BNY Mellon and Ocean Park Advisors, LLC’s Investment Bank where I was involved in equity and debt capital raising transactions as well as M&A assignments, liquidity forecasting and assessments, business plan due diligence, development of waterfall and recovery analyses, stakeholder negotiations, plan of reorganization development, M&A/transaction advisory including purchase and sale negotiations and seller due diligence support, board/shareholder representation, developing executive compensation/bonus plans, and ad-hoc strategic and operational assessments.
JAVI MALCOLM
MD 
Strategic Development
Dr Malcom’s Medical Professional qualities are based on 10+ yrs. of participation and exposure to numerous resources as an ER Medical Business Co-Founder, IT Market Leader, Mentor, Red Cross Humanitarian Participant, Graduate of Masters Studies, Graduate of Medical Doctorate (M.D.), Hospital Administrator, and member of the Physician Executive Team. My unique background and combination of these attributes & skills have created a unique innovative space that helps reinforce my ability to grasp the different areas of healthcare that positively impact the hospital ecosystem and be a valuable member of the C-Suite team, as DHR Health’s Chief Medical Information Officer, Physician Executive Leadership Committee, and the Cerner Advisory Committee.
Dr. Jill Taylor
DO Pharmacologist
Chief Clinical Officer​

It is important to learn about the doctor with whom you trust your health. A combination of formal education, training, and experience form Dr. Taylor’s credentials, which uniquely qualify her to provide you with the best approach to achieving your optimum health

Here are a few highlights:

  • Specializing in Family Practice. Fully licensed in Texas
  • Graduated New York Institute of Technology, New York College of Osteopathic Medicine 1989
  • Worked in Medical, Drug, and Disease Research for three years as a Pharmacologist
  • Worked in academic medical research for three years
  • Holds patents in Disease Research
  • Has publications in several Medical Journals
  • Speaks Medical Spanish
NARIO CANTU
Pharmacist
Senior Executive Director
Dispensing, assessing and monitoring medications, in patients requiring pharmaceutical therapy. Providing and assessing point of care testing. Providing excellent service and customer satisfaction. Drug information and education. hospital readmission prevention consultant, transition care provider, medication reconciliation provider, pharmacogenomic testing, point of care testing. Medication Therapy Management, medication adherence and legislative advocate as it pertains to pharmacy and patient care.
SABRINA RUNBECK
MPH, MHS, PA-C
Director People & Clinical Outcomes 

Physician Assistant turned Entrepreneur with Bachelor in Neuroscience, Masters in Public Health and Health Sciences, After working 80 hours a week as a cardiothoracic surgery physician associate, my workload took a toll on my personal and professional life. That was when I realized my life needed to change. I ended up taking a deep dive into performance sciences and positive intelligence. As a result, I cut down my clinical hours by 30% and increased my income by 50%.

Reggie Abraham
PhD, MHA, MBA
Managing Director  
UTHealth-MRG Health

Experienced Healthcare Executive with a demonstrated history of working in a hospital setting and various other health care facilities. Skilled in Healthcare Operations, EHR & PM Systems, Budgeting, HR Management, Strategic Planning, and Revenue Cycle Management, . Strong business development professional with a Doctorate in Management and Organizational Leadership, Master’s in Healthcare Administration, Master’s in Business Administration. Exceptional track record of establishing strong leadership teams and developing effective operational efficiencies in healthcare operations. Establish and maintain good working relationships with physicians, staff, vendors, government agencies, managed care companies, and clients.

KYLE CHRISTOPHER
Vascular General, Cardiac, OB Sonography
Founder/CEO - Strategic Development  
Assists Physicians and Healthcare Executives in Leveraging Virtual Care Management Technologies, NEW Billable CPT Codes, and Value Based Care Models to Improve Clinical Outcomes and Create NEW Revenue streams. Kyle holds a Bachelors of Science in Business Administration with a minor in marketing, and a Degree in Vascular, General, Cardiac, and Obstetrical Sonography. His philanthropy work focuses on veteran affairs, single mothers, first responders, and mentoring terminally ill and at-risk youth through organizations such as Beauty for Freedom, Ferrari Kid, Southwest Keys Program, ICON Talks, and Living Beyond A Dream.