TCM is a focused program for members transitioning from an acute or post-acute facility back to the community. Essentially from moment of discharge (zero gap in care) until 30 days from index facility discharge, a RN Case Manager facilitates the patient’s care in collaboration with the healthcare team to address short term barriers – setting members up for success in their home during the most critical window of recovery. Benefits of TCM include stabilizing and optimizing the member’s health and recovery to help reduce avoidable re-admissions.