Transitional Care Management (TCM) - Prevent Readmissions

Seamless Care Transitions & Readmission Prevention

Transitional Care Management (TCM) provides intensive support for Medicare beneficiaries during the critical 30-day period following hospital discharge, skilled nursing facility discharge, or other inpatient stays. This high-risk period sees readmission rates of 15-20% when patients lack adequate support. Our TCM program ensures patients receive timely follow-up care, understand discharge instructions, obtain prescribed medications, and have questions answered before complications arise.

The TCM platform facilitates the required communication with the patient or caregiver within 2 business days of discharge, schedules face-to-face visits within 7 or 14 days (depending on medical complexity), and coordinates with hospital discharge planners and community resources. Care coordinators reconcile medications, review warning signs, arrange necessary services, and ensure patients attend follow-up appointments. The system tracks all TCM activities to support Medicare billing (CPT 99495, 99496) and generates documentation demonstrating the interactive contact, care plan development, and coordination activities required for reimbursement.