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Since the institution of the Transitional Care Management billing codes by the Centers for Medicare and Medicaid Services in 2013, primary care practices nationwide have worked to meet expectations and provide high-quality care to patients upon discharge from hospitalization. In St. Albans, Vermont, the complexity of preparing for successful transitions of care has challenged family medicine providers and supporting staff. Thus, this project sought to provide a structured process by which the primary care team may communicate with inpatient staff, the patients, and each other and collect information required to ensure smooth transitioning of the patient back into the setting of their "medical home."

Clinical Site

St. Albans Primary Care


TCM, transitions of care, quality improvement, vermont, family medicine, checklist

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Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.


Medical Education | Primary Care