Transitional Care Management

True Value Based Healthcare

Our Care Transitions Program’s overarching goal is improve health outcomes for patients and a reduction in 30-day readmissions post hospitalization. Our robust program integrates true care coordination through our unique platform with dedicated healthcare professionals to deliver effective TCM.    Care Transitions works to assure patient's adherence to the physician prescribed discharge plan, follow-up with their treating providers post-discharge, and improves conditions through extensive education and coordination of needed services.    

Reimbursed under CPT code 99495 / 99496, we capture new revenues for hospitals and physician practices while positively impacting quality metrics and lowering 30-day readmission rates and penalties.

Patient Focused

Turn-key care coordination from our skilled healthcare professionals to deliver better care and improved outcomes.


Core Program Elements:

  • All CMS compliance requirements for TCM under CPT codes 99495 / 99496
  • Additional outreach to monitor patients and catch health challenges during the 30-day period
  • Proactive triage to provide care consumate with healthcare challenges
  • Extended Patient Education - teaching the warning signs of complications
  • Adherence to prescribed physician follow-up care 
  • Adherence to the physician prescribed discharge plan 
  • Coordinating access to primary care and needed community services  

Partnering For Success

Quality Care + Expanded Patient Touches =  

Improved Clinical Metrics and Increased Business Revenues     

Our integrated care programs deliver seamless workflow and interfaces that expand revenues and improve key quality metrics without increasing staff or overhead.