Transitional Care Management (TCM) typically focuses on the post-discharge period when patients transition from a hospital or other healthcare facility to their home or another setting. It aims to support patients during this critical period to reduce the likelihood of readmissions, and complications, and improve overall health outcomes.
Transitional Care Management
Reimagine and redefine the post-acute care continuum. Interact with patients to guarantee quality of care during the important 30-day post-discharge period.
Carelink's Transitional Care Management Services provide support to patients as they move between different healthcare settings or stages of care, promoting seamless transitions, enhancing results, and minimizing potential complications.
20% Readmission
Approximately 1 in 5 Medicare beneficiaries in the US are readmitted in the hospital within 30 days of discharge.
76% Readmission
Approximately 1 in 5 Medicare beneficiaries in the US are readmitted in the hospital within 30 days of discharge.
Do you know
What is Transitional Care Management?
An expert care that adapts to the speed of life
Why choose Carelink's Transitional Care Management?
Our HIPAA-compliant cloud-based software application is designed specifically for managing patients in care transitions. It automates your entire care transition workflow – from enrolling the patient and creating the electronic care plan to reconciling medications, scheduling & documenting phone calls, and generating reports needed for billing purposes.
Key Features
How it Works?
Our solutions acts as an enabler to schedule face-to-face appointments, extend care remotely, access real time patient-health information through bi-directional integration with EHRs.
An interactive dashboard with access to patient information and various tools for providers to deliver TCM activities efficiently.
During the transition period from an inpatient hospital to the community setting, TCM servicing generally fall into three categories.
Interactive Contact
This can be made via email, telephone, or face-to-face contact within 2 business days following a patient's discharge to a community settings.
Non face-to-face Service
Obtaining/reviewing discharge information, connecting with healthcare professionals, education and support for scheduling follow up, treatment regimen adherence and medication management.
Face-to-face Visits
Face-to-face visits may also be completed, generally within 7 to 14 days depending on Medical decision complexity of the patient being discharged from the hospital.
Associated CPT Codes by CMS Transitional Care Management
