Everyday Care

Transitional Care Management in South Florida

The weeks after a hospital stay are the riskiest. We see you quickly, reconcile every medication, and coordinate the next steps - so recovery happens at home, not back in the hospital.

Call (561) 498-5660 Book at your nearest office

Trusted since 1987

A man in a white coat reviewing a tablet with another man beside a hospital room

What it is

A Medicare-supported program for the high-risk weeks after discharge.

Who it is for

Patients leaving a hospital, skilled nursing facility, or rehab center.

Where

All three PPC offices.

Timing

Follow-up typically within one to two weeks of discharge, sooner for higher-risk patients.

Cost

A covered service for Medicare beneficiaries.

The first weeks home

Tap a phase to see what happens when.

Before you leave

Coordination starts early

Hospital team contact
Records in hand

We connect with the hospital team so discharge instructions, test results, and the medication list arrive with you - not weeks later by fax.

Tell us a discharge is coming and the coordination starts before you are home.

First days home

Medication reconciliation

Duplications caught
Dose changes checked

Full medication reconciliation. Hospital med changes are the number one source of post-discharge errors - we catch duplications, omissions, and dose changes.

Our pharmacist and your physician review the complete picture together.

Your follow-up visit

Typically within one to two weeks

Sooner if higher-risk
Warning signs checked

Typically within one to two weeks, sooner if you are higher-risk. Warning signs get checked early, when they are cheap to fix.

Call as soon as a discharge date is known and we hold the right slot.

The written plan

Plain language, on paper

Recovery steps
Who to call

Recovery steps, warning signs, who to call - on paper, in plain language, shared with your family if you want.

Everyone helping your recovery works from the same page.

Readmissions are often preventable. Prevention is a phone call: (561) 498-5660.

What is Transitional Care Management?

Transitional Care Management is a Medicare-supported program that supports patients in the weeks right after a hospital, skilled nursing, or rehab stay - with prompt follow-up, medication review, and coordinated next steps - available at all three PPC offices.

The days after discharge are when complications most often occur: medication confusion, missed follow-ups, warning signs nobody caught. National data shows a significant share of readmissions are preventable with proper follow-up - and that is exactly what this program does.

Because TCM happens inside your primary care home, the physician reviewing your recovery already has your history, your baseline, and your full medication list.

Is this right for you?

Check whatever sounds like you. Nothing is sent anywhere - this stays on your device.

You or a family member is being discharged from a hospital or facility soon

The discharge came with new or changed medications

You are worried about managing recovery at home

You have been readmitted to a hospital before and want to avoid it

You want one practice coordinating the hospital team, specialists, and home health

See what this means

Who is TCM not for?

If you are having a medical emergency during recovery - fever with a surgical wound, chest pain, trouble breathing, signs of stroke - call 911 or return to the ER.

If your hospital stay was for a planned procedure with a surgeon managing all follow-up, your surgeon's plan leads; we coordinate the rest of your care around it.

If you were not recently discharged from a facility, regular primary care visits are the right door.

How does TCM work?

Before discharge

Tell us (or have family tell us) a discharge is coming. We start coordinating with the hospital team early.

First days home

Medication reconciliation - catching duplications, omissions, and dose changes made in the hospital - plus a review of discharge instructions.

Weeks one and two

A prompt follow-up appointment, sooner for higher-risk patients, with a clear written plan for continued recovery.

TCM questions, answered

What is Transitional Care Management?+

It is a Medicare-supported program for the high-risk weeks after discharge from a hospital, skilled nursing facility, or rehab center. PPC provides a prompt follow-up appointment, full medication reconciliation, review of discharge instructions and results, coordination with hospital teams and home health, and a clear written recovery plan.

Is Transitional Care Management covered by insurance?+

For Medicare beneficiaries, TCM is a covered service. If you or a family member is being discharged, contact your PPC office as soon as possible so the follow-up window is not missed - timing is what makes the program work.

How soon after discharge will I be seen?+

Typically within one to two weeks, and sooner for higher-risk patients. Call your nearest office as soon as a discharge date is known - Boca Raton, Delray Beach, or Hallandale Beach - and we will hold the right slot.

Why does medication reconciliation matter so much?+

Hospitals often change, stop, or add medications, and those lists do not always match what you were taking before. Duplications, omissions, and dose errors are the most common source of post-discharge problems. Our pharmacist and physicians review the complete picture together.

Can family members arrange this for a parent or spouse?+

Yes - family members call us all the time when a discharge is coming. With the patient's permission, we coordinate directly with family and home health services throughout recovery.

Medically reviewed by Dr. Danielle Neuman, MD - Medical Director, Personal Physician Care. Last reviewed August 2026.