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Transitional Care Management

Critical Support After Discharge

Transitional Care Management (TCM) provides crucial support during the 30 days after hospital discharge, the period when patients are most vulnerable to complications and readmission.

app.hosscare.com / patients
Active patients2,847
MC
Margaret Chen· MRN-4827-019
Normal
JP
James Park· MRN-3318-204
Review
AR
Aisha Rahman· MRN-9912-008
Out of range
DA
Diego Alvarez· MRN-6543-117
Normal
SK
Sarah Kim· MRN-2204-441
Normal
app.hosscare.com / dashboard
RPM Patients
2,847
12% vs. last mo
Time-in-Range
87.4%
3.1pp
Audit Pass Rate
100%
last 90 days
Reimb. Mins
94k
18%

Why Transitional Care Management?

The first 30 days after discharge are critical. TCM helps ensure patients recover successfully.

Smooth Transitions

Ensure patients successfully transition from hospital to home or other settings.

Timely Outreach

Contact patients within 2 business days of discharge as required.

Medication Reconciliation

Review and reconcile medications to prevent adverse events.

Readmission Prevention

Reduce 30-day readmissions through proactive follow-up care.

TCM Services

Comprehensive transition support

Our TCM program includes all required elements for billing plus additional services to ensure your patients have the best chance of a successful recovery.

Interactive contact within 2 business days
Face-to-face visit within 7 or 14 days
Medication reconciliation and management
Care coordination with specialists
Referral to community resources
Patient and caregiver education
Follow-up appointment scheduling
24/7 access for urgent needs
RPM · Hypertension
Cycle 03 · Day 14 of 30
On track
  1. Eligibility verified
    Apr 02 · Auto-checked
  2. Device shipped & paired
    Apr 04 · BP cuff
  3. 16 / 20 readings logged
    In progress · 4 days left
  4. Provider review & bill
    Scheduled May 02
65%

Ready to reduce readmissions?

See how Transitional Care Management can help your patients transition safely while generating revenue.

Book a demo