Transitional Care Management for Providers

Effective post-discharge planning is essential to prevent patients from falling through the cracks after leaving the hospital. TCM ensures a seamless handoff from inpatient to outpatient care, incorporating timely follow-ups and thorough communication among care teams. This structured approach helps healthcare providers maintain continuity of care, identify early signs of complications, and intervene proactively.

TCM is not only about patient care; it’s also a tool for operational efficiency. By following CMS guidelines for timely patient contact and follow-up visits, providers can streamline their workflow while delivering high-touch, coordinated care. This structured protocol helps standardize post-discharge procedures across care teams, reducing variability and ensuring each patient receives consistent attention during a critical recovery window.

TCM services are reimbursable under Medicare, offering a valuable opportunity for providers to enhance revenue while delivering high-quality care. Providers who adhere to CMS requirements for TCM are eligible for higher reimbursements than standard office visits. By integrating TCM into their practice, healthcare organizations can boost profitability while contributing to Value-Based Care goals.

Patients benefit from TCM through reduced hospital readmissions, better medication adherence, and stronger relationships with their care teams. Structured follow-ups not only help manage chronic conditions and medication regimens, but also reinforce patient education, empowerment, and trust. This comprehensive support system results in improved recovery, fewer emergency department visits, and higher satisfaction with the healthcare experience.

Clinii streamlines the implementation of TCM protocols, helping providers coordinate timely post-discharge follow-ups, monitor care transitions, and document all necessary touchpoints for compliance. Clinii’s platform automates reminders, centralizes communication, and integrates with EMR systems to ensure every eligible patient is enrolled in the appropriate TCM pathway.

With Clinii, providers can unlock the full financial and clinical potential of TCM. Our platform ensures that all CMS criteria are met, from prompt patient outreach to accurate billing documentation. In doing so, Clinii helps practices capture maximum Medicare reimbursements while reducing readmissions and improving patient outcomes.