A Trusted Next Step for Your Most Complex Patients
Texas Integrated Care Group partners with hospitals, skilled nursing facilities, memory care communities, home health agencies, and referring providers across Montgomery County to provide physician-led post-discharge follow-up and long-term chronic disease management for medically complex adults.
When medically complex patients leave the hospital or transition between care settings, what happens next matters enormously. Delayed follow-up, medication changes, fragmented communication, and poor continuity of care are common drivers of preventable readmissions and worsening chronic illness. Texas Integrated Care Group was created to help close that gap through a more proactive, coordinated approach to internal medicine focused on stabilization, continuity, and long-term disease management.
Who We Accept Referrals For
We are an ideal next step for patients who are:
What We Offer Your Patients
Transitional Care Management (TCM) We provide timely post-discharge follow-up within established Transitional Care Management timeframes through telehealth, home-based visits, or office follow-up when appropriate. Visits focus on medication reconciliation, discharge review, symptom reassessment, care coordination, and reducing the risk of avoidable readmissions.
Early referral notification is encouraged to support timely scheduling and continuity of care after discharge.
Chronic Care Management (CCM) For patients with two or more chronic medical conditions, we provide structured longitudinal care management that includes regular clinical touchpoints, care plan oversight, medication monitoring, preventive support, and coordination with specialists and caregivers.
Remote Patient Monitoring (RPM) Appropriate patients may be enrolled in remote monitoring programs designed to track vital signs and clinical trends between visits, allowing earlier identification of deterioration and more proactive intervention.
Behavioral Health Integration (BHI) For patients whose medical conditions are complicated by depression, anxiety, cognitive concerns, or other behavioral health needs, we incorporate behavioral health support into the broader medical care plan.
Advanced Internal Medicine Visits We offer comprehensive, physician-led visits designed around medical complexity rather than patient volume — allowing additional time for medication review, chronic disease management, care planning, caregiver concerns, and long-term treatment discussions.
Why Referring Providers Choose Texas Integrated Care Group
We aim to work collaboratively with referring physicians, specialists, discharge teams, caregivers, and community partners to support safer transitions of care and improved long-term outcomes for complex patients.
How to Refer a Patient
Step 1 Contact our office by phone or email at the time of discharge or transition of care.
Step 2 Provide patient demographics, insurance information, discharge summaries, medication lists, and any relevant clinical documentation.
Step 3 Our team will coordinate timely outreach to the patient or family to arrange appropriate follow-up care.
Contact Information
Phone: +1 (469) 267-1172
Email: info@texasintegratedcaregroup.com
For urgent post-discharge referrals, please call directly to help facilitate priority scheduling coordination.
Serving Patients Across Conroe, The Woodlands, Spring, Huntsville, And The Greater Montgomery County Area
with coordinated, patient-centered healthcare services. Telehealth services may also be available across other areas of Texas when clinically appropriate, helping improve access to quality care and long-term health outcomes.
