• hospital
• clinic
• Compass HQIC
• care transitions
• care management
• HQIN
• TCM

Care transitions, particularly from an inpatient setting to home, can be a challenging time for patients who may be dealing with a medical crisis, a new medical condition, or change in care plan. Poor transitions of care can lead to a variety of negative outcomes, including medication discrepancies, adverse clinical events, poor patient experience of care, and frequently avoidable hospitalizations. Improving care transitions has been an important strategy for reducing the costs associated with hospitalization and readmissions¹ and proves to be an important opportunity for addressing social determinants of health². Transitional Care Management (TCM) serves to manage this hand-off period offering an excellent opportunity for primary care providers to oversee and coordinate support for a patient's medical conditions, mental health or behavioral health needs, social services, and other barriers to optimal patient outcomes.

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