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.

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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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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

  • Improve care continuity and patient outcomes post-discharge.
  • Reduce hospital readmission rates through structured follow-ups.
  • Strengthen patient relationships with proactive care coordination.
  • Enhance clinical efficiency by streamlining transitions of care.
  • Support better health outcomes with a standardized care process.
For Patients
  • Ensure smooth recovery after hospital discharge with guided support.
  • Reduce the risk of complications and avoid unnecessary readmissions.
  • Get help managing medications and follow-up appointments.
  • Stay connected to your care team during a critical recovery period.
  • Receive personalized attention tailored to your condition and needs.

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.

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(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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Solutions

  • Revenue Cycle Management
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  • Principal Care Management
  • Tramsitional Care Management

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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.