• Cook County: 7620 Gross Point Rd. Skokie IL 60077 Lake County: 28140 N. Bradley Rd. Libertyville IL 60048
  • 847.297.4444

For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, Transitional Care Model emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management – all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient’s physicians.

Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible for, including the quality of care during the hospitalization and the discharge planning process. However, it is clear that there are multiple factors along the care continuum that impact readmission’s, and identifying the key drivers of readmission’s for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions.The (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

An alarming rate of one in five Medicare beneficiaries are rehospitalized within 30days of being discharged from a hospital. The rate nearly doubles among those with high-risk medical, functional and cognitive conditions. Assure safely transitions high-risk patients from the hospital or other facility to home and prevents unnecessary rehospitalizations by providing a specially trained team of licensed, nurse and social worker geriatric care managers who coordinate care in the home.

Transitional Care Management Model

Assure’s  TCM Consistently delivers improved patient outcomes and reduced cost of care among high-risk patients by aiding in the reduction preventable readmissions by engaging, educating and empowering the patient in self-management best practices.

Specially Trained Transitional Care Nurses and Social Workers Services

  • TCM RN Visit the  patient prior to discharge from the hospital and multiple times in the home
  • Assessing medical, functional and environmental needs
  • Developing and implementing individualized transition care plan in patient’s home

Primary Care Coordination to Maintain Health and Function

  • Setting up follow-up doctor appointments
  • Medication reconciliation
  • Seamless collaboration with health professionals, family members, and care teams