Transitional Care Management
Safe Transitions from Hospital to Home
The days following a hospital discharge are among the most vulnerable in a patient's healthcare journey. Sterling Health Solutions's Transitional Care Management program provides structured follow-up, real-time ER encounter notifications, and comprehensive care coordination to prevent readmissions and ensure safe recovery.
What is Transitional Care Management?
A structured program to bridge the gap between hospital and home
Transitional Care Management (TCM) is a structured care program designed for patients who have been recently discharged from a hospital inpatient stay, emergency room visit, or skilled nursing facility. The program is built around the recognition that the first 30 days after discharge represent a high-risk period during which patients are most vulnerable to complications, medication errors, and hospital readmission.
At Sterling Health Solutions, our TCM program provides immediate post-discharge outreach, comprehensive medication reconciliation, a face-to-face clinical visit, and ongoing care coordination for the full 30-day post-discharge period. Every step is designed to catch problems early, ensure patients understand their discharge instructions, and connect them with the follow-up care they need.
TCM is a Medicare-recognized service, meaning these critical transitional care activities are covered for eligible beneficiaries. Our program benefits patients, their families, referring physicians, and hospital systems alike by reducing readmissions and improving outcomes during the most vulnerable phase of recovery.
Real-Time ER Encounter Notifications
Immediate awareness when your patients visit the emergency room
Closing the Information Gap
One of the biggest challenges in post-discharge care is knowing when a patient has visited the emergency room. Many ER encounters go unreported to the patient's primary care provider and care team, leading to missed opportunities for early intervention that could prevent a full hospital readmission.
Sterling Health Solutions integrates with regional health information exchanges (HIEs) and admission-discharge-transfer (ADT) notification systems to receive real-time alerts whenever one of our managed patients visits an emergency room anywhere in our network area.
When we receive an ER encounter notification, our care team initiates immediate outreach. We contact the patient, review the reason for the ER visit, coordinate with the discharging facility, reconcile any medication changes, and schedule an expedited follow-up visit. This rapid response capability is a cornerstone of our readmission prevention strategy.
The TCM Process
A proven, step-by-step approach to safe post-discharge transitions
Discharge Notification
When a patient is discharged from a hospital, emergency room, or skilled nursing facility, our system receives a real-time notification. This triggers the TCM process immediately, ensuring no patient falls through the cracks during the critical transition period.
Contact Within 48 Hours
A member of our clinical care team contacts the patient by phone within 48 hours of discharge. During this call, we review discharge instructions, confirm medication changes, assess the patient's current condition, identify any barriers to recovery, and schedule the face-to-face follow-up visit.
Face-to-Face Visit Within 7–14 Days
A provider conducts a comprehensive in-person visit within 7 to 14 days of discharge, depending on the complexity of the patient's condition. This visit includes a full assessment, medication reconciliation, care plan review, and coordination with specialists and primary care physicians.
Ongoing Care Coordination
TCM doesn't end with the face-to-face visit. Our team continues to coordinate care for 30 days post-discharge, managing follow-up appointments, monitoring for warning signs of complications, and ensuring the patient has the support needed for a complete recovery.
The Readmission Problem
Hospital readmissions are costly, common, and largely preventable
3.8M
Annual hospital readmissions in the U.S.
~20%
of Medicare patients readmitted within 30 days
$26B
Annual cost of unplanned readmissions to Medicare
75%
of readmissions considered potentially preventable
How TCM Reduces Readmissions
Research published in the Journal of the American Medical Association and other peer-reviewed sources consistently shows that structured transitional care programs significantly reduce 30-day readmission rates. The key factors are early contact after discharge, thorough medication reconciliation, a timely face-to-face visit, and ongoing care coordination.
Sterling Health Solutions's TCM program addresses all of these factors systematically. By combining real-time ER notifications with structured follow-up protocols, we create a safety net that catches problems during the critical post-discharge window — before they escalate into readmissions.
For Hospitals & Facilities
Partner with Sterling Health to improve outcomes and reduce penalties
Reduce Readmission Rates
Hospital Readmissions Reduction Program (HRRP) penalties can cost facilities millions. Our TCM services directly reduce 30-day readmission rates for discharged patients, improving your quality metrics and protecting your bottom line.
Real-Time ER Notifications
Our system integrates with health information exchanges to receive real-time alerts when your patients visit any emergency room. This enables immediate outreach and intervention before a situation escalates to a full readmission.
Seamless Care Continuity
We serve as an extension of your discharge planning team, ensuring that every patient receives structured follow-up regardless of whether they have an established primary care provider. No patient is left without a safety net.
Quality Reporting Support
Our detailed documentation and outcome tracking support your quality reporting requirements, including CMS Star Ratings, value-based purchasing metrics, and bundled payment program compliance.
TCM Success Stories
How transitional care management has made a difference
“After my husband was discharged from the hospital, we were overwhelmed with new medications and follow-up instructions. The Sterling team called the very next day, walked us through everything, and scheduled a home visit within the week. Without that support, I'm certain he would have ended up back in the ER.”
Linda C.
Caregiver, Richardson
“As a hospitalist, I've seen too many patients bounce back within days of discharge. Since partnering with Sterling Health for TCM services, our 30-day readmission rate has dropped significantly. Their ER notification system catches issues we would have otherwise missed.”
Dr. Michael P.
Hospitalist, Dallas
Prevent Readmissions. Improve Outcomes.
Whether you are a patient transitioning home from the hospital, a family caregiver seeking support, or a healthcare facility looking to reduce readmissions, Sterling Health Solutions is here to help. Contact us today to learn more about our TCM program.