Transitional Care Management
We Stay With You After the Hospital
Leaving the hospital can feel uncertain. Ternion Physician Group's TCM program means a physician is actively monitoring your recovery for the full 30 days after discharge — so you and your family don't have to navigate it alone.
52%
Fewer hospital readmissions at Ternion-supported facilities
72 hrs
Our team contacts you within 72 hours of discharge
7 days
In-person physician visit for complex patients
30 days
Physician oversight throughout your full recovery window
What is TCM?
The weeks after discharge matter more than most people realize.
Transitional Care Management (TCM) is a structured, physician-led service that bridges the gap between your hospital stay and your return to home or a community setting. It was created by the Centers for Medicare and Medicaid Services (CMS) to prevent the complications and return hospitalizations that most commonly occur in the 30 days after discharge.
At Ternion Physician Group, TCM isn't a checkbox — it's an active, physician-driven process. We reach out within 72 hours, review your medications, update your care plan, and see you in person within 7 days if your needs are complex. Our goal is simple: make sure nothing slips through the cracks while you recover.
TCM services include:
- Coordinated care between providers
- Medication management and review
- Patient and caregiver education
- Care planning for the next 30 days
TCM is a structured CMS-defined service. Ternion physicians are experienced in managing the full 30-day post-discharge window across Arizona's skilled nursing and post-acute facilities.
The 30-Day Process
What happens after you leave the hospital
TCM services follow a structured timeline designed to catch problems early and keep your recovery on track.
First Contact
Within two business days of discharge, our team contacts you or your caregiver by phone. We review your discharge instructions, confirm your medications, and make sure you have a clear plan for the days ahead. You won't be left wondering what to do next.
In-Person Physician Visit
For patients with complex medical needs, one of our physicians sees you face to face within 7 days of discharge. For moderate complexity, this visit occurs within 14 days. This is a real clinical visit — not just a phone check-in — to assess your recovery, review medications, and adjust your care plan if needed.
Ongoing Monitoring
Throughout the full 30-day window, our team monitors your recovery, coordinates specialist referrals, tracks pending test results, and remains available when something doesn't feel right. You have a physician in your corner — not just a nurse line.
What You Can Expect
Physician support every step of the way home
72-Hour Outreach
Our team contacts you within 72 hours of discharge to review instructions, confirm medications, and make sure you have a clear plan for the days ahead.
Medication Reconciliation
We go through every medication with you, ensure your list is accurate, and explain what each one is for — one of the most common sources of post-discharge complications.
Updated Care Plan
We review everything the hospital sent home with you — new diagnoses, pending results, follow-up needs — and make sure your care plan reflects your current condition.
Face-to-Face Physician Visit
For patients with complex needs, a physician sees you in person within 7 days of discharge to assess your recovery, answer questions, and adjust your care if needed.
Follow-Up Coordination
Specialist appointments, pending imaging, referrals — we track all of it and make sure nothing gets lost so you're not chasing down appointments on your own.
Family Communication
We explain your care plan in plain language, answer questions from family members, and make sure everyone knows what to watch for and when to call us.
Who Qualifies
Is TCM right for you or your loved one?
To qualify for TCM services, a patient must be discharged from a qualifying care setting and have documented medical records indicating a need for continued physician oversight. The type and intensity of care varies based on diagnosis complexity, medication burden, and risk factors.
Qualifying discharge settings
- Skilled nursing facility (SNF)
- Inpatient acute care hospital
- Inpatient psychiatric facility
- Partial hospitalization program
- Hospital outpatient observation
- Long-term care hospital (LTCH)
Common conditions we manage
- Heart failure (CHF)
- COPD or breathing difficulties
- Recovery from sepsis or serious infection
- Diabetes with complications
- Post-surgical recovery
- Stroke or neurological conditions
- Multiple hospitalizations in the past year
- Complex medication regimens
Insurance Coverage
Does insurance cover TCM?
In most cases, yes. TCM services are covered under Medicare Part B for eligible beneficiaries — particularly those at higher risk of readmission or with complex medical needs. Some private insurers also cover TCM, though pre-authorization may be required. Our team can help you understand what's covered before services begin.
Medicare Part B
Most Medicare beneficiaries qualify for TCM coverage, especially those with complex conditions or a history of readmission. Coverage should be verified to confirm service qualifications are met.
Private Insurance
Many private insurers cover TCM services, though coverage varies by plan. Pre-authorization may be required. Our team can help you navigate what your plan covers.
For Caregivers
Questions to ask your TCM care team
Navigating a loved one's recovery can feel overwhelming. Here are the questions that matter most — bring them to your first contact with our team.
Talk to our team- How do I reach the physician or care team if something changes?
- What medications were changed at discharge, and what is the correct schedule?
- What warning signs should prompt us to call — or go to the ER?
- When is the in-person physician visit scheduled?
- Are there activities or tasks to avoid during recovery?
- What specialist follow-ups are needed, and who is coordinating them?
- Is any medical equipment needed at home after discharge?
- What community resources or home health services are available?
Have questions about care after discharge?
Our team is here to help you and your family understand what to expect and how we can support your recovery. Reach out — we're glad to talk.