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Transitional Care Management (TCM) Services

Inova's Transitional Care Management (TCM) program replaces the former HeartLink program and provides assistance with a safe transition home for patients previously hospitalized with diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).

TCM offers a free, 30-day, phone-based coaching program after the patient is discharged from the hospital or emergency room. The phone calls are conducted by health coaches and case managers who review the following topics:

  • Medication review for accuracy and education
  • Timely medical follow up
  • Signs and symptoms for early intervention
  • Education about the illness to support improved self management
  • Resources available in the community

To enroll in the TCM program, patients can request a referral from an Inova Emergency Department or a hospital case manager. For questions regarding referrals and program details, contact the TCM department at 571-623-3360.