Required patient transitional care management (TCM) services include:
- Supporting a patient’s transition to a community setting
- Health care professionals who accept patients at the time of post-facility discharge, without a service gap
- Health care professionals taking responsibility for a patient’s care
- Moderate or high complexity medical decision making for patients with medical or psychosocial problems
The 30-day TCM period begins on a patient’s inpatient discharge date and continues for the next 29 days. TCM services begin the day of discharge from 1 of these inpatient or partial hospitalization settings:
- Inpatient acute care hospital
- Inpatient psychiatric hospital
- Inpatient rehabilitation facility
- Long-term care hospital
- Skilled nursing facility
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a community mental health center
After inpatient discharge, the patient must return to their community setting. These could include:
- Home
- Domiciliary (such as a group home or boarding house)
- Nursing facility
- Assisted living facility