Returning Home After Hospital Care: What Comes Next

Transitional Care Can Organize Recovery and Medical Follow-Up

Leaving the hospital is an important milestone, but recovery does not end at discharge.

Patients and caregivers may return home with new medications, follow-up appointments, activity restrictions, testing instructions, and warning signs to monitor. Transitional Care Management can help organize this information and connect the patient’s hospital care with the next stage of recovery.

What Is Transitional Care Management?

Transitional Care Management, commonly called TCM, is structured follow-up for eligible patients leaving certain inpatient settings.

UrgentCare2go® offers in-home and virtual TCM services for patients transitioning from hospitals, skilled nursing facilities, inpatient rehabilitation, and certain other qualifying settings.

The goal is to help patients and caregivers understand the discharge plan, identify potential gaps, and coordinate appropriate medical follow-up.

What May Be Included?

Depending on eligibility and medical needs, transitional care may include:

• Contact soon after discharge

• Review of hospital instructions

• Medication reconciliation

• Assessment of current symptoms

• Coordination with primary care and specialists

• Review of scheduled tests and appointments

• Patient and caregiver education

• Development or clarification of the ongoing care plan

UrgentCare2go’s program describes contact within two business days, followed by an in-home or virtual visit within seven or 14 days based on the complexity of the patient’s condition.

Why Medication Reconciliation Matters

Hospital stays frequently result in medication changes. A medication may be added, discontinued, adjusted, or temporarily prescribed.

During medication reconciliation, the healthcare professional compares the discharge list with the medications the patient was taking before admission. This process can identify duplicate medications, confusing instructions, or questions that need clarification.

Patients should never discontinue or change a prescription without guidance from an appropriate healthcare professional.

How to Prepare for a Transitional Care Visit

Keep these items available:

• Hospital discharge paperwork

• Current medication bottles

• Updated medication list

• Insurance information

• Recent test results

• Specialist appointment details

• Home blood pressure or glucose records, if applicable

• Questions from the patient or caregiver

A family member or caregiver may also participate when the patient permits it.

Watch for Concerning Symptoms

Patients should follow the warning instructions provided by the hospital. Seek immediate help for serious symptoms such as:

• Chest pain

• Severe breathing difficulty

• New confusion

• Signs of stroke

• Uncontrolled bleeding

• Loss of consciousness

• Rapidly worsening symptoms

Call 911 for a possible emergency.

Transitional Care at Home or Virtually

UrgentCare2go provides eligible in-home and virtual transitional-care options. Virtual TCM appointments may be available across Texas, while mobile availability depends on the patient’s location.

Service communities include Dallas–Fort Worth, Arlington, Farmers Branch, Brownwood, Austin, Houston, San Antonio, and El Paso.

Learn more about UrgentCare2go Transitional Care Management, submit a patient referral, or call (817) 508-8169.

Eligibility, appointment timing, covered services, and patient costs depend on discharge circumstances, medical complexity, insurance requirements, and clinical review.