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Transition Support Case Management (TSP CM) is a collaborative process performing the primary role functions of assessment, planning, facilitation, and advocacy for options and services to meet a patient's health needs post discharge. Responsibilities include assisting the client and/or family caregivers with follow through of discharge plan and homecare instructions to prevent rehospitalization. In this role, the TSP CM empowers patients and their families towards greater autonomy and improved health and safety outcomes post discharge. The TSP CM will serve all high-risk medical clients including, but not limited to, vent dependent clients and clients with disorders of consciousness. This process requires an organized individual with excellent communication skills. The TSP Case Manager is an integral part of a patient's recovery process, helping to continue coordinating the efforts began by the interdisciplinary rehabilitation team.
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