A safe transition from hospital to home is a critical part of recovery, but for many patients it can feel overwhelming. Missed follow-up appointments, medication confusion and limited support can all increase the risk of complications or hospital readmission.
MultiCare Rockwood Clinic’s Transitional Care Management (TCM) program is designed to help patients through this vulnerable period. Through timely outreach, clear communication and coordinated follow-up, the care team supports a smoother, more confident recovery.
The program bridges the gap between hospital discharge and ongoing primary care. By helping patients schedule the right follow-up appointments, resolve barriers early and get connected with the services they need to recover safely at home, Rockwood’s TCM team plays a key role in our commitment to patient-centered care.
Strengthening the path from inpatient to outpatient care
In 2025, Rockwood advanced this work in several important ways.
One key step was improving documentation workflows so care teams can more easily identify patients who need transitional care before they leave the hospital. This improvement helps physicians and advanced practice providers correctly identify care management needs at discharge, supporting timely follow-up once patients return home.
Rockwood’s RN care manager also partnered with a local infusion coordinator to support patients who require outpatient IV antibiotic therapy. Together, they worked with primary care providers to clarify roles and begin care planning earlier — while patients were still hospitalized — so services could be in place as soon as patients were discharged.
The result: fewer delays during hospital stays, better alignment with length-of-stay reduction efforts and more timely coordinated support for patients as they transition back home.
Supporting social needs that influence recovery
Because recovery depends on more than medical care alone, Rockwood also developed quick-reference resource guides to help care teams connect patients with community support. These guides address key needs such as homelessness, housing, mental health, caregiver support and transportation.
By making these resources easier to access, care teams can help reduce barriers that might otherwise slow recovery or increase the risk of readmission.
Measurable impact
Rockwood’s TCM program maintained a 4.1 percent readmission rate, well below the general rate of 8.1 percent. This outcome reflects the program’s structured outreach, early coordination and strong follow-up practices.
By combining practical tools, strong partnerships and nurse-led coordination, Rockwood continues to improve hospital-to-home transitions and support better outcomes for patients.
Want to learn more or partner with us?
Explore how Rockwood’s Transitional Care Management program is improving recovery and reducing readmissions. We welcome collaboration and new ideas. Email us at [email protected].
Written by: Jose Mari Lansang, RN, Director of MultiCare Nursing for Primary Care & Population Health