What is transitional care management?

Transitional care management is a service that helps your primary care doctor coordinate and manage your health care after you are released from a hospital or other health care facility. The service consists of a phone call from a member of ISG to you or your caregiver within two business days after you have been released. This is followed by an appointment within 7 to 14 calendar days.

Why is transition of care important?

After you are released from a hospital or other health care facility, managing your health condition and knowing who to call if your condition gets worse can be complicated. Transitional care management allows your care team to communicate with you or your caregiver to offer the best possible way to manage your condition. The coordination of your care may help improve your quality of life, reduce your anxiety, and prevent an unnecessary hospital readmission.

After emergency room visits or hospitalization, does my primary care doctor’s office receive my records?

Some hospitals and emergency rooms release your information immediately, but this is not always the case. When you are being discharged, ISG staff will release your records to your primary care doctor.

What can I expect from my primary care doctor after a discharge from a hospitalization?

A member of ISG will call you or your caregiver after you are released from the hospital within two business days. We will review your information with you, such as discharge instructions, doctors’ orders, and medicines. We will help coordinate community resources, if necessary, and schedule an office appointment with an ISG doctor.

When can I expect an appointment with ISG after a hospitalization?

You can expect an appointment within 7 to 14 calendar days after a hospitalization.

Is there a cost to this service?

This service is covered by Medicare Part B and most commercial insurances. It is subject to the usual deductible and coinsurance.

What else do I need to know?

Unless it’s a life-threatening emergency, you should call your primary care doctor first to help manage your care. The care team at ISG can coordinate care with your primary care doctor, other doctors, hospitals, or health care facilities.