A plan for the transition
Keep the discharge plan connected to daily life.
Transitional care management (TCM) is a clinician-provided service for eligible patients moving from a qualifying care setting back into the community. It includes specific contact, visit and care-coordination requirements. A phone check-in by itself does not fulfill the whole service.
KindlyMoments is designed to support regular phone check-ins as part of your care plan. Scheduled calls give you a familiar way to describe your routine and raise questions for the care team.
Situations this may support
- Returning home after a hospital stay or surgery.
- Transitioning from skilled nursing or rehabilitation.
- Adjusting to a new medication or follow-up routine set by the clinician.
- Bringing family or authorized caregivers into the plan.
Who makes the care decisions?
The independent clinical partner determines eligibility, directs the care plan, performs clinical visits and reviews concerns routed through the workflow. The automated assistant does not replace that clinician.
Prepare for a conversation
When you meet the clinical team through their secure process, have the discharge instructions and your usual clinician’s contact details available. Do not upload or email those records through this public website.
For general background: Medicare’s transitional care management information.
Ask about transition support