Approximately 1 in 5 Medicare beneficiaries in the US are readmitted in the hospital within 30 days of discharge.
An efficient TCM program is estimated to prevent up to 76% of the readmission rates and in-turn uplift patient outcomes.
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.
"An expert care that adapts to the speed of life"
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.
Allowing ease of use and incorporation into existing workflow
Initiating an interactive contact with the patient within the first two days of discharge.
Reviewing the discharge summary and discharge instructions with the patient or caregiver.
Coordinating care with other health care professionals who may assume or resume care.
Providing seamless knowledge transfer to the patient or caregiver.
Determining any needs that exist by coordinating care with community organizations for the patient.
Providing medication reconcillation.
Scheduling and automatically reminding the patient of required physician follow-ups or additional services.
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.
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.
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 may also be completed, generally within 7 to 14 days depending on Medical decision complexity of the patient being discharged from the hospital.
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It includes:
• Communication within 2 days of discharge
• At least moderate medical decision making
• Face-to-face visit, within 14 calendar days of discharge
It includes:
• Communication within 2 days of discharge
• At least moderate medical decision making
• Face-to-face visit, within 7 calendar days of discharge
Transitional Care Management (TCM) collects patient data encompassing medical history, current health status, medications, care plans, contact details, appointments, and insurance/billing information. This data is crucial for seamless transitions between healthcare settings, minimizing complications, and optimizing health outcomes.
Transitional Care Management (TCM) involves identifying eligible patients, assessing their needs, coordinating care, managing medications, providing education and support, monitoring progress, and planning transitions. These stages aim to optimize patient outcomes and enhance care quality during healthcare transitions.
Patients transitioning from an inpatient hospital stay, skilled nursing facility, or similar healthcare settings to their home or another care setting are typically eligible for Transitional Care Management (TCM) services.
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