Healthcare System Context: Current & Future changes
Amid a changing healthcare environment, TCN is committed to preserving non-profit community-based care for serious illness. TCN is also committed to ensuring that inter-disciplinary, person-centered care is available to all patients with serious illness to improve outcomes, enhance experience, and manage costs.
Our Solution: Care Model
Patient and Family-Centered
- The care team delivers advance care planning over time at the person’s own pace and in their preferred setting—they educate, counsel, and support patients and their caregivers on treatment options and decisions.
- Transitions from inpatient settings are coordinated along with community-based services and supports to ensure the patient has everything they need to be stable and comfortable in a home-based setting
- We see all of the providers that serve a patient and caregiver as a team—we connect and supplement the team to ensure optimal execution of the individualized care plan
Who we are: Recognized leaders in palliative & serious illness care
TCN is a non-profit network of high-quality palliative and advanced illness providers with a commitment to innovation, performance, and service to our communities.
What we provide: Integrated system of community-based services
Core Clinical Services Include:
- Care coordination and transitional care across clinically adjacent and social supports services
- Multidimensional health risk assessment, including ensuring medical record information is accurate, up-to-date, and complete
- Goal setting and comprehensive care plan
- Comprehensive advance care planning
- Proactive clinical and symptom management including pain management
- Medication management and reconciliation
- Health coaching, care training, psychosocial support
- Caregiver support
- Home safety and access adaptations