Transitional Care Management

Transitional Care Management Services Offered In Phoenix, AZ

Navigating transitions in healthcare can be challenging, but at Active Vital Care, we’re here to support you every step of the way. Our transitional care management services ensure a smooth transition from one healthcare setting to another, whether it’s from hospital to home or between different levels of care. We coordinate with other healthcare providers to ensure continuity of care and help you achieve optimal health outcomes.

What is Transitional Care Management?

  • Transitional Care Management services address the hand-off period between the inpatient and community setting.
  • After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy.


Key Components of Active Vital Care Transitional Care Management Services:

  • Continuity of Care: Active Vital Care ensures seamless care during transitions from inpatient to outpatient settings.
  • Medication Reconciliation: Reviewing and managing medications to prevent adverse effects or interactions.
  • Post-Discharge Follow-Up: Regular follow-up appointments to monitor progress and address any issues.
  • Coordination with Specialists: Collaborating with specialists involved in the patient’s care.
  • Patient Education: Providing information on self-management, lifestyle changes, and preventive measures.


Benefits of Transitional Care Management:

  • Reduced Readmissions: TCM aims to prevent hospital readmissions by providing comprehensive post-discharge care.
  • Improved Patient Outcomes: Continuity of care enhances patient outcomes and satisfaction.
  • Personalized Support: Active Vital Care tailors TCM services to each patient’s unique needs.