Transitional Care Management (TCM) Team
Supporting You Safely from Hospital to Home
Leaving the hospital is an important step in your recovery — but it can also feel overwhelming. Our Transitional Care Management (TCM) Team is here to guide you through the next phase of care, ensuring a safe, smooth transition from the hospital to your outpatient provider and home.
We work closely with our KU Hospitalist teams at Via Christi St. Francis and Wesley to reduce complications, prevent readmissions, and support your recovery.
What Is Transitional Care Management?
Transitional Care Management is a coordinated approach to care for patients recently discharged from the hospital. Our team monitors and supports patients after discharge to ensure:
- Medications are accurate and understood
- Follow-up appointments are scheduled and kept
- Symptoms are monitored closely
- Questions and concerns are addressed quickly
- Care plans are clearly communicated
- Resources are provided for barriers to care
Who We Serve
Our TCM services are available to patients who:
- Have recently been discharged from the hospital
- Have complex medical conditions
- Require medication adjustments
- Need assistance coordinating follow-up care
- Are at higher risk for hospital readmission
Our Services
1. Rapid Post-Discharge Outreach
We contact patients within 48 business hours of discharge to:
- Review discharge instructions
- Assess symptoms and recovery status
- Identify immediate concerns
2. Appointment Coordination
We assist with scheduling follow-up visits with:
- Your KU Wichita Clinic primary care provider within 14 days from hospital discharge
3. Patient & Caregiver Education
We help patients and families understand:
- Warning signs to watch for
- Medication instructions
- Lifestyle recommendations
- When to seek urgent care
Why Transitional Care Matters
Transitions between care settings are one of the most vulnerable times in a patient’s healthcare journey. Our team helps to:
- Reduce preventable hospital readmissions
- Improve medication safety
- Increase patient confidence and understanding
- Strengthen communication between providers
- Support long-term health outcomes
Contact the Transitional Care Management Team
If you have recently been discharged and have questions about your care, please reach out to us.
Phone: (316) 516-3746
Office Hours: Monday–Thursday, 8:00 AM – 5:00 PM, Friday 8:00 AM-12:00PM
If you are experiencing a medical emergency, call 911 immediately.