Transitional Care Management

Support that begins before patients change settings

Transitions place patients at the highest risk of complications. It’s vital that patients moving from hospital to facility, and from facility to home receive follow-up care and support. Lumina Care’s Transitional Care Management (TCM) program helps patients return home with a clear plan, coordinated care, and support in place.

Transitional Care Management

Support that begins before patients change settings

Transitions place patients at the highest risk of complications. It’s vital that patients moving from hospital to facility, and from facility to home receive follow-up care and support. Lumina Care’s Transitional Care Management (TCM) program helps patients return home with a clear plan, coordinated care, and support in place.

Transitional Care Management

Support that begins before patients change settings

Transitions place patients at the highest risk of complications. It’s vital that patients moving from hospital to facility, and from facility to home receive follow-up care and support. Lumina Care’s Transitional Care Management (TCM) program helps patients return home with a clear plan, coordinated care, and support in place.

Understanding the power of Transitional Care Management

Transitional Care Management supports patients during one of the most vulnerable points in their care journey. By guiding patients through the first days and weeks after discharge, Lumina Care helps prevent medication errors, confusion about follow-up, and delays that often lead to complications.

Providers benefit from clearer visibility into patient progress, fewer avoidable readmissions, and better continuity across settings. Patients gain confidence, timely support, and a smoother path toward recovery.

20%

Patients with post-discharge adverse events

Complications

Fewer ED visits, rehospitalizations, and lower mortality after discharge among Medicare patients where TCM codes were used

Complications

Fewer ED visits, rehospitalizations, and lower mortality after discharge among Medicare patients where TCM codes were used

55%

Post-discharge care interventions lowered readmissions by 18-55%

Capabilities

Transitional Care Management by Lumina Care

Patient care

  • Discharge and care planning begins before transitioning home 

  • Medication management is carefully adjusted to limit complications

  • At-home services coordinated to support ongoing recovery

  • Access to 24/7 clinical support

  • Ongoing care oversight to identify changes requiring follow-up

  • Recommendations made for returning patients to the facility for care, when appropriate, to avoid hospitalization

Clinical collaboration and operations

  • In-depth coordination with facility staff and PCPs

  • CMS-aligned workflows simplify reimbursement

  • EMR-integrated documentation supports compliance and follow-up

  • Continuous visibility into patient progress without added workload

  • Hospitalization data shared with facilities and marketing teams to support admissions and referrals

  • Reporting on services not being delivered and causes of hospital transfers

Capabilities

Transitional Care Management by Lumina Care

Patient care

  • Discharge and care planning begins before transitioning home 

  • Medication management is carefully adjusted to limit complications

  • At-home services coordinated to support ongoing recovery

  • Access to 24/7 clinical support

  • Ongoing care oversight to identify changes requiring follow-up

  • Recommendations made for returning patients to the facility for care, when appropriate, to avoid hospitalization

Clinical collaboration and operations

  • In-depth coordination with facility staff and PCPs

  • CMS-aligned workflows simplify reimbursement

  • EMR-integrated documentation supports compliance and follow-up

  • Continuous visibility into patient progress without added workload

  • Hospitalization data shared with facilities and marketing teams to support admissions and referrals

  • Reporting on services not being delivered and causes of hospital transfers

Real-life results with TCM

Client:

Size: 50+ SNFs across the Northeast

Solution: Transitional Care Management

Outcome:

Within a month of beginning our TCM program, the client saw immediate and sustained reductions in hospitalizations among residents returning home. As a result, the TCM program is expanding, supporting more residents as they transition from facility to community-based settings.

Talk to an expert

Connect with Lumina Care and learn how we enhance your team’s capabilities, improve care outcomes, and relieve the burden on your staff.

Talk to an expert

Connect with Lumina Care and learn how we enhance your team’s capabilities, improve care outcomes, and relieve the burden on your staff.

Talk to an expert

Connect with Lumina Care and learn how we enhance your team’s capabilities, improve care outcomes, and relieve the burden on your staff.

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