Transitional Care Management
Transitional Care Management
Transitional Care Management (TCM) is a healthcare program designed to bridge the gap between a patient’s hospital discharge and their return home. This crucial period can be challenging, and TCM programs aim to reduce the risk of readmission by ensuring a smooth and coordinated transition.
Once your patients have been discharged from the hospital, you’d rather not see them come back. Unfortunately, a fifth of Medicare beneficiaries are readmitted within a single month, leading to combined costs of more than $25 billion – and counting.
CMS has recognized that monitoring patients between office visits and hospital stays dramatically reduces their chances of seeking emergency inpatient care.
Our Difference
We’re well-designed to address the primary factors leading to readmission, namely inadequate follow-up care, lack of patient education, and poor coordination between healthcare providers. For evident reasons, avoiding hospital visits translates to improving health outcomes, and thus increased patient satisfaction.
TCM programs and others, specifically RPM and CCM, provide clinical care and digital applications for patient education, improved medication adherence, early intervention, and continuity of care across providers and settings.
Our TCM programs have proven to reduce emergency care visits and readmission rates. In fact, case studies have shown that patients enrolled in our care management programs were 50% less likely to have a readmission than those not enrolled in the program.
Our proven patient engagement solutions are a win-win for all: integrated TCM workflows reduce administrative burdens, care gaps are closed, costs are reduced, providers are financially rewarded for keeping patients out of the hospital, and above all, patients stay healthy at home.
Medicare Billable Codes
Medicare billable codes for TCM include:
- 99495: Moderate complexity face-to-face visit within 14 days of discharge
- 99496: High complexity face-to-face visits within 7 days of discharge
Transitional Care Management Features + Benefits
Ease of Use
First by incorporation into your existing workflow
Interactive Content
Initiating interactive contact with patients within the first two days of discharge
Discharge Summary
Reviewing discharge summary and discharge instructions with the patient or caregiver
Easy Care Transfer
Coordinate care with other health professionals who may assume or resume care
Education Transfer
Provide education to the patient or caregiver
Care Coordination
Determine any patient needs that exist, coordinating care with community organizations
