Transitional Care Management for Providers
Drive better outcomes and boost Medicare revenue with Clinii’s Transitional Care Management. Seamlessly coordinate post-discharge care, reduce readmissions, and support patient recovery with follow-up and care coordination tools designed for healthcare providers.
What is Transitional Care Management?
Transitional Care Management (TCM) focuses on providing support and continuity
of care for patients transitioning from a hospital setting to other care environments, aiming to reduce readmissions and improve health outcomes.
1. Optimize Post-Discharge Planning
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.
2. Maximize Provider Efficiency
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.
3. Opportunities for Reimbursement
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.
4. Improved Patient Outcomes and Satisfaction
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.
5. How Clinii Supports Providers With TCM
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.
6. Leveraging Clinii to Optimize Reimbursement and Recovery
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.
Frequently Asked Questions About Transitional Care Management
1. Which healthcare professionals, specifically physicians or non-physician practitioners, may provide non-face-to-face services as part of TCM?
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Physicians (any specialty)
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Non-physician practitioners (NPPs) legally authorized and qualified to provide the services in the state where they practice:
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Certified nurse-midwives (CNMs)
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Clinical nurse specialists (CNSs)
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Nurse practitioners (NPs)
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Physician assistants (PAs)
CNMs, CNSs, NPs, and PAs may provide non-face-to-face TCM services “incident to” services of a physician and other CNMs, CNSs, NPs, and PAs.
2. What are some hospital settings from which a patient may transition during the TCM process?
Allowable settings include:
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Long-term care hospital
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Inpatient acute care hospital
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Inpatient psychiatric hospital
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Skilled nursing facility
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Inpatient rehabilitation facility
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Hospital outpatient observation or partial hospitalization
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Partial hospitalization at a community mental health center
3. How soon after discharge should a patient be contacted for TCM services?
For a patient to qualify for TCM services under Medicare, they must be contacted within two business days of discharge from an inpatient setting. This initial communication—via phone, email, or face-to-face—ensures timely care coordination and helps identify any immediate post-discharge needs. Additionally, a face-to-face visit must occur within seven or 14 days of discharge, depending on the complexity of the patient’s medical condition.