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This initiative aimed to enhance the post-discharge process to improve care quality and reduce missed follow-ups.Methods:We implemented a streamlined follow-up process for stroke patients discharged home, aligning with the Centers for Medicaid and Medicare (CMS) definition of the Transitional Care Management (TCM).
This initiative, led by Advanced Practice Providers (APPs), aimed to refine the post-discharge process to enhance care quality and reduce missed follow-ups.Methods:We introduced a streamlined follow-up process for stroke patients discharged home, adhering to the Centers for Medicaid and Medicare (CMS) Transitional Care Management (TCM) model.
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