Hospital Follow Up

Defining “discharge”

For the purpose of TCM, “discharge” refers to a discharge from an inpatient setting such as an acute care hospital, rehabilitation hospital, long-term acute hospital, or skilled nursing facility. It also refers to discharge from observation status in a hospital, or from a partial hospital program, which is a program for mental health and substance abuse disorders that involves spending the day at the treatment center and the night at home. No other discharges are allowed under the guidelines. Emergency department discharges are excluded, as well as discharges from assisted living facilities.

The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.

Transition of Care – TCM SERVICES SETTINGS

TCM services are furnished following the beneficiary’s discharge from one of these

• Inpatient Acute Care Hospital
• Inpatient Psychiatric Hospital
• Long Term Care Hospital
• Skilled Nursing Facility
• Inpatient Rehabilitation Facility
• Hospital outpatient observation or partial hospitalization
• Partial hospitalization at a Community Mental Health Center

Additional Resources

TCM – TRANSITIONAL CARE MANAGEMENT SERVICES