Transitional Care Management Services
Medicare may cover these services if you’re returning to your community after a stay at certain facilities, like a hospital or skilled nursing facility. You’ll also be able to get an in-person office visit within 2 weeks of your return home.
The health care provider who’s managing your transition back into the community will work to coordinate and manage your care for the first 30 days after you return home. They will work with you and your family and caregiver(s), as appropriate, and with your other health care providers.
The health care provider may also:
- Review information on the care you got in the facility
- Provide information to help you transition back to living at home
- Work with other care providers
- Help you with referrals or arrangements for follow-up care or community resources
- Help you with scheduling and managing your medications.