What is Transitional Care?: Everything You Need to Know

• Transitional care supports discharged patients as they move from one care setting to another, such as returning home or transferring to another care facility. This type of care encompasses a broad range of transitions and healthcare services. 
• When transitional care is recommended, a patient is assigned a transitional care manager or unit who will help coordinate appointments with healthcare providers, promote medication adherence, and communicate with the patient’s healthcare providers. 
• If a patient meets certain requirements, Medicare Part B will cover most transitional healthcare costs. 

When someone is discharged from the hospital, they need time to rest and recover. But there are also follow-up appointments to coordinate, prescriptions to fulfill, and ongoing treatment to arrange. For eligible patients, a transitional care manager can help tick off those to-dos and make the first 30 days at home easier. 

Transitional care coordination is a service that helps patients navigate their recovery after leaving the hospital. A dedicated care manager or team bridges the gap between inpatient care and outpatient care by organizing post-discharge medical needs and providing patients with information about what to expect at home. Typically, these services are covered partially or in full by your private insurance or Medicare. Transitional care managers are an invaluable resource to provide great care for patients and their families. 

Continue reading to learn more about what transitional care management is, who qualifies, and how it can lead to better healthcare outcomes and patient well-being. 

Transitional care supports the movement patients make to different locations, such as moving from a hospital to a nursing home or returning home after surgery. If that definition sounds broad, it’s because TCM is a versatile option. Someone transitioning from the hospital after an illness to an assisted living facility, for example, may qualify for transitional care, as will someone returning home after heart surgery.

Typically, patients who qualify for TCM often have a complex recovery process that requires careful planning and coordination. It can be hard to transition back home, set up occupational therapy, coordinate multiple appointments with different specialists and social services, and research the best home ramp to purchase. Transitional care helps manage these tasks and provides expert insight when making recovery decisions. 

Who is Eligible?

Transitional care managers are most likely to be assigned to patients over 65 who have one or more chronic conditions. However, anyone diagnosed with a mid-to-high-complexity medical condition, such as liver cancer or COPD, that requires continuing care from multiple medical providers is eligible. 

As the name suggests, qualifying patients are also transitioning care settings. Usually, the patient is being discharged from a hospital, skilled nursing facility, long-term acute care facility, or inpatient rehabilitation care facility. They typically return home or to a community setting like an assisted living home. However, patients who qualify can move from one inpatient healthcare setting to another as well.

Most of these patients stayed 21 days or less in inpatient care, though that isn’t an official requirement. Someone in intensive inpatient care, such as for cancer treatment, may also qualify. 

What Transitional Care Includes

According to the U.S. Centers for Medicare and Medicaid Services, transitional care is available for the first 30 days after someone returns home. Before an inpatient discharge, a transitional care manager or unit will review the details of care received at the hospital or skilled nursing facility.

During the 30 days, the manager or unit helps with:

• Setting up medical appointments
• Discharge planning
• Coordinating rehabilitation services, such as physical therapy
• Ensuring patients receive high-quality care
• Facilitating home care, if required
• Providing fall prevention services
• Checking on medical equipment deliveries and set-ups

TCM services sometimes include recommendations or referrals for home health equipment, community resources, or medical providers. They may also include home visits, though the transitional care appointment format depends on who is providing the transitional care and a patient’s insurance.

Transitional Care Managers 

Transitional care teams provide TCM services to patients recovering after an inpatient stay. Transitional care ensures licensed nurses are available, though other licensed healthcare workers, such as nurse practitioners, physician’s assistants, social workers, and trained volunteers can also fulfill this role. These professionals help coordinate care and any other required medical services. Care managers or units are assigned by hospitals or healthcare systems. 

Many healthcare providers, including Oak Street Health, assign one care manager per patient, ensuring the patient’s point of contact is consistent. That way, patients and loved ones have one person’s name and contact information instead of trying to reach out to multiple care providers.

Managers also collaborate with a family member or caregiver, answering any questions they have about their loved one’s treatment plan. They are also in regular communication with clinicians who provide ongoing care to the patient. 

The first 30 days after discharge from a hospital or inpatient facility are full of health risks and potential service fees. A successful recovery period lowers these risks and helps patients contain costs.

Specific benefits of transitional care include:

• Lower hospital readmission rates
• Better medication adherence 
• Smarter usage of healthcare and community resources
• Reduced medication errors
• Improved functional outcomes, meaning that an individual has a smoother recovery socially and at work
• Higher satisfaction with care
• Better clinical outcomes, including improved quality of life and a positive change in symptoms

Along with these tangible benefits, many patients and their loved ones find that working with a transitional care manager reduces stress and confusion around receiving healthcare and adjusting to life at home after a hospital discharge. A transitional care manager is an invaluable partner to answer any questions and coordinate care when life feels overwhelming. 

As discussed, this healthcare service is broad. Within it, there are different subtypes of care, including inpatient hospital stay to home, skilled nursing facility to home, and transfers within hospital units. 

For all these subtypes, two types of care are provided: face-to-face services and non face-to-face services. Face-to-face services are the tasks seen by patients and family caregivers. They include many responsibilities we already discussed, like scheduling medical appointments, educating patients and loved ones, and helping patients fulfill prescriptions. 

Non face-to-face services are those that make recovery smoother, but are often hidden from patients and their loved ones. Non-face-to-face services include:

• Ensuring continuity of care by connecting all healthcare professionals who are helping the patient
• Assessing the needs and diagnostic tests
• Improving communication between all care providers
• Documenting all care in one centralized place so all healthcare providers are aware of the patient’s care journey
• Filing documentation to insurance companies so care is more affordable

Combined, these services promote a safety culture where patients feel secure and empowered as they navigate their healthcare needs. High-quality transitional care is a combination of the two service types and results in fewer hospital readmissions and better healthcare outcomes. 

No matter the type of transitional care, researchers have found some best practices. Patients should look for hospitals that demonstrate these best practices, including:

• Flexible communication methods: offering patients transitional care via telehealth or a hybrid model with some in-person and online options makes it easier for patients to follow a recovery plan. 
• Communication-focused transitional care: a 2023 study found the use of a post-discharge phone call to patients or their loved ones, consistent communication with outpatient providers, and a discharge summary reduced hospital readmissions and emergency room visits. 
• Context-based transitional care: transitional care should be context-specific as opposed to a one-size-fits-all model. 
• Safety-centered services: managers should facilitate a safe and timely passage back into a home or community setting. 
• Minimal complexities: researchers rate transitional care on a scale of low to high complexity. Recent research suggests low to mid complexity transitional care delivers better results for patients. 

Transitional care is covered by Medicare Part B when someone is moving from the hospital or an inpatient care facility back to their home or a community setting, such as a nursing home. The exact transitional care services covered by original Medicare are specific and may not be as comprehensive as those covered by private healthcare or Medicare Advantage (MA) plans. 

For the first 30 days after a hospital discharge, Medicare covers:

• A safe coordination and on-time discharge
• Assistance with scheduling follow-up medical appointments
• Education about returning home and treatment options 
• Referrals for follow-up care 
• Referrals to community resources when applicable
• Help with medications

Most of these services are completed asynchronously, as Medicare Part B typically covers one in-person office visit with a transitional care manager within two weeks of discharge.

If someone has a private insurance plan, including a MA plan, the exact services covered will depend on their policy, provider, and plan benefits. Usually, someone on a private insurance plan has to get pre-authorization before their insurance will cover TCM. 

Out-of-pocket costs with Medicare

While covered by both Original Medicare and Medicare Advantage plans, there are some out-of-pocket costs. First, Medicare beneficiaries are responsible for their Part B monthly premiums ($202.90 in 2026). There’s also a Part B coinsurance on TCM (usually 20% of the billed amount). Transitional care also contributes to the Part B deductible (the set amount a patient must pay before Medicare covers treatments). In 2026, that deductible is $283.

For more information surrounding what Medicare covers when it comes to transitional care, reach out to an insurance provider to discuss your benefits and the specifics of your plan.

If someone has a private insurance plan, as opposed to Medicare or Medicare Advantage, coverage for transitional care costs depends on their policy and provider. Usually, these patients must get pre-authorization before their insurance will cover this service. 

To qualify, a patient must meet the standards discussed above (discharged from an approved site and diagnosed with a mid to high-complexity medical condition). A healthcare system or hospital should alert eligible patients before they are discharged and will assign a TCM manager as part of discharge planning. TCM service should be provided without a patient or a loved one requesting them.

If, however, someone feels they or a loved one do qualify and the services haven’t been mentioned, they should bring up transitional care with a doctor or nurse. Healthcare providers can connect patients with any services required and answer any questions, ensuring a healthy recovery.