About/Mission/Goal
Transitional Care refers to coordinated medical oversight services that streamline the discharge process for patients moving from one care setting to another, typically from a qualifying medical facility to your home.
Transitional Care Management (TCM) is a recognized 30-day, Medicare-covered benefit. TCM services include various outpatient services and some preventative care services. It is designed to ensure that each individual patient receives a smooth transition back to their community after discharge, from hospital to home, for both patients and family members.
Our mission is to provide appropriate clinical oversight, coordinated and continuous care in multiple aspects, and reduce the disparity in the transition process from one setting to another for each individual patient. Well Care Family aims to avoid adverse events such as readmissions and complications. Our goal is to ensure you receive continuity of care during this vulnerable 30-day discharge period, including a transition as stress-free as possible for our patients and their family—whether it’s mental, emotional, or environmental.
Servicing Area: We are servicing San Diego County, Orange County, and Los Angeles County.
Your Personalized, Certified Clinical Transitional Care Team
Your care team begins with a Nurse Practitioner and Registered Nurse, overseen by a physician, and coordinated in conjunction with your in-patient facility and primary care provider(s).
At the first meeting with you and your family, either before or shortly after your discharge, we work together to assess your individual post-discharge needs and formulate your treatment plan.
Your personal Care Nurse is on call for you 24/7, by telephone and e-mail, and will help you with everything from medical oversight, home care coordination, follow-up appointments, questions and understanding of your condition, and providing all necessary resources to help you manage your health condition at home.
Our focus is on your care and coordinating a smooth transition for you and your family, so that you can focus on healing.
Costs and Benefits
Transitional Care Management (TCM) is not a brand-new Medicare benefit. However, a growing rate of Medicare members have found TCM to be useful and beneficial to their healing and recovery since its introduction to Medicare coverage in 2013. It is now a recognized outpatient service under Medicare Part B. There is ZERO cost to you other than your existing copay with Medicare Part B.
Medicare patients also have the option to extend the Transitional Care services past the 30-day period.
Self-Pay Options
For Medicare-ineligible patients or patients that wish to contract our services privately, we offer our 30-day services at an affordable out-of-pocket option.
Self-pay options are also eligible for Section 125 cafeteria plan reimbursements.