GRMC Launches Transitional Care Clinic

Guam Regional Medical City (GRMC) recently launched a Transitional Care Clinic (TCC) to better serve patients and improve outcomes. The objective is to reduce hospital re-admissions and provide an additional layer of support for GRMC patients post hospitalization. The TCC will be within GRMC’s Multispecialty Clinic located on the 1st floor of the hospital and GRMC’s internal medicine team will serve as the TCC providers.

There are unique challenges to ensuring a safe discharge for hospital inpatients given the island’s limited resources. A TCC visit will entail the following elements:

• Evaluation of medical and/or psychosocial problems indicated as moderate or high level of medical decision making.
• Initial contact with the patient through a phone call within two business days AFTER discharge.
• Within 7-14 days, a face-to-face visit is required with a primary care provider or one of GRMC’s TCC providers.
• If the patient chooses GRMC’s TCC, Transitional Care Management (TCM) services will continue for 29 days after discharge to allow the patient access to contact clinical staff or the provider by phone for any related questions.
• The patient must consent to having a TCC visit and TCM services at GRMC.

The GRMC TCC is not intended to compete with primary care clinics, rather it is to augment and support the existing medical infrastructure and bridge a gap of service. For those patients with existing primary care providers, GRMC will not attempt to schedule a post hospitalization TCC visit unless the patient’s primary care provider is unable to accommodate or schedule the appropriate follow up within the required 7 to 14-day timeframe. If a patient chooses GRMC’s TCC services, they will revert to their primary care provider after the 30-day TCM period. For those patients evaluated as needing TCM services who do not have a primary care provider, GRMC will immediately offer the service.

For more information about the GRMC Transitional Care Clinic, please contact Eric Plinske, Chief Business Development Officer at eric.plinske@grmc.gu.