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.