Transitional Care Management (TCM) Overview & Benefits



TCM Overview


Transitional Care Management is a program designed to support and track Medicare patients in the 30 days following discharge from a hospital or treatment facility. Approximately 1 in 5 Medicare beneficiaries in the US are readmitted to the hospital within 30 days of discharge – a 20% readmission rate. TCM programs are designed to connect healthcare providers and patients during this critical 30 day period attempting to change this post acute continuum of care by helping to better manage patients to improve health outcomes and keeping readmission rates down. 


Using HIPAA compliant software, TCMs help manage the hospital inpatient to community setting transition through scheduling, remote care management and the ability to access patient information in real time through electronic health record (EHR) integration – delivering seamless and efficient TCM support and intervention throughout this critical 30 day window.


TCM programs typically fall into 3 categories of care:


Interactive Contact – some form of contact occurs (phone, email,…) within 2 business days of discharge


Non Face-to-Face Services – reviewing discharge information, conferring with other members of healthcare team, education and support for follow up scheduling, treatment regimen adherence and medical management. 


Face-to-Face Visits – completed within 7-14 days  


Benefits of TCM


Statistically, support and management of patients in the days following discharge yield better health outcomes, lower costs and decrease in return hospitalization. 


Efficient and Effective TCMs can:


– Improve Health Outcomes

– Increase Patient Engagement

– Lower Mortality Rates

– Reduce Readmission

– Reduce Costs of Care

– Potentially increase revenue


A successful, well-executed and efficient TCM program can prevent 76% of readmissions.  


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