Transitional Care Services

What is Transitional Care Services? (TCS)

TCS includes services provided to a patient whose medical and/or psycho social problems require moderate or high complexity medical decision making during transitions in care from an in-patient hospital setting (includes skilled nursing facility, rehabilitation hospital) to the patient’s community setting whether that be home, domicile, nursing home or assisted living.

Scope of Services under TCS:

  • Assist with hospital discharge, review discharge information or continuity of care documents
  • Scheduling appointments for diagnostic tests and treatment, including follow-ups with community service provider and services
  • Provide education to the beneficiary, family, guardian and/or caregiver
  • Assess and support treatment regimen adherence and medication management (including prescription pick-up).