Your Partner in Post-Discharge Care
We provide personalized support, follow-up care, and medication management after discharge to help patients recover safely and move from one healthcare setting to another—reducing hospital readmissions and closing care gaps.
Our Transitional Care Management Goals
Transitional Care Management (TCM) is a set of services designed to support patients during a critical period when they move from one healthcare setting to another, whether that be from a hospital to their home or to a care facility. AWP Healthcare's TCM goals include preventing care gaps, assisting with medication changes, and reducing hospital readmissions.
Our Transitional Care Management Benefits
TCM supports patients during a vulnerable point in their care journey, after a hospital or facility discharge. With early outreach, care coordination, and medication guidance, TCM helps patients recover safely, avoid unnecessary setbacks, and stay connected to their providers. It’s a path to better outcomes and fewer readmissions.
Our Process
Our team connects with patients within two days of discharge to support a smooth transition from hospital to home or care facility. Within the first week, patients receive a virtual visit with a nurse practitioner to guide recovery.
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Services & Support
Services & Support
We coordinate referrals with community resources, schedule primary care and specialist follow-ups, and ensure continuity of care every step of the way. -
Medication Management
Medication Management
As part of our Transitional Care Management services, we complete a comprehensive medication reconciliation to ensure accuracy and safety. Our team educates patients on their medication regimen and evaluates compliance to support better outcomes. We also handle prior authorizations to ensure seamless access to prescribed medications without delays.
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Accessible & Covered
Accessible & Covered
Our Transitional Care Services are delivered via telehealth, allowing patients to receive expert support from the comfort of home—making recovery easier and more accessible. These services are also covered by Medicare and many Medicare Advantage plans, with no added costs beyond any applicable co-pays or co-insurance.
Services & Support
We coordinate referrals with community resources, schedule primary care and specialist follow-ups, and ensure continuity of care every step of the way.
Medication Management
As part of our Transitional Care Management services, we complete a comprehensive medication reconciliation to ensure accuracy and safety. Our team educates patients on their medication regimen and evaluates compliance to support better outcomes. We also handle prior authorizations to ensure seamless access to prescribed medications without delays.
Accessible & Covered
Our Transitional Care Services are delivered via telehealth, allowing patients to receive expert support from the comfort of home—making recovery easier and more accessible. These services are also covered by Medicare and many Medicare Advantage plans, with no added costs beyond any applicable co-pays or co-insurance.Ready to Simplify Post-Discharge Care?
Whether you’re ready to take the next steps or just want to learn more, we’re here to support you. Better recovery starts here.
