Roughly one in five Medicare patients is readmitted within 30 days of discharge, and most of those readmissions trace back to the same problems: medication confusion, missed follow-up appointments, and nobody to call when something changes. Transitional care management fixes that with a defined plan: contact within two business days, a full medication reconciliation, a telehealth visit within 7 to 14 days, and a clinician who answers the phone for the rest of the month.