You’ve probably seen or heard about how certain patients who got discharged from the hospital suddenly had a turn for the worse and need to be readmitted once again. This is because of that critical period where the patient is discharged and will transition back into a home or community setting. That period requires adequate after-care services. Otherwise, the patient could end up being back at the hospital and in a worse state than before. This is where Transitional Care Management (TCM) is needed the most. Let’s discuss what TCM is and how an innovation like telehealth can make things easier for patients undergoing this stage.

What is Transitional Care Management?

Transitional care management is designed for primary care doctors and specialists, as well as non-qualifying medical practitioners, for the care they provide to patients who have been discharged from hospitals and other facilities. This includes services provided to a patient with medical and/or psychosocial problems that require moderate or high-complexity medical decision-making. 

TCM works to improve care coordination for Medicare patients between the acute care setting and community setting. This is why the  Centers for Medicare and Medicaid Services (CMS) created two billing codes for TCM. For a number of reasons, patients with moderate or high-complexity medical issues will eventually get discharged from the hospital or a care facility. This shift is a crucial time frame as anything can happen at this time. During this period, chances of readmission are increased if proper transition and quality of care are not provided.

The essence of TCM is that a healthcare provider takes charge of the patient’s care from the instant they’ve been discharged. Ideally, TCM should last up to 30 days and involves a medical professional engaging in face-to-face visits. However, with the advent of telehealth services, non-face-to-face meetings are more encouraged now. 

Eligibility Requirements for TCM

To be eligible for TCM, patients must be discharged from an acute setting to their home setting, such as the patient’s residence, domiciliary, rest home, or assisted living facility. The acute setting can be any of the following:

  • Inpatient Acute Care Hospital
  • Inpatient Psychiatric Hospital
  • Long-Term Care Hospital
  • Skilled Nursing Facility
  • Inpatient Rehabilitation
  • Hospital Outpatient Observation
  • Partial Hospitalization

How TCM Benefits from Telehealth Services

Through telehealth and virtual care, post-acute care organizations can engage their patients and coordinate and optimize care at every interaction during a TCM program. Face-to-face visits aren’t always ideal, especially if medical professionals aren’t available to visit their patients or if they live too far from the nearest healthcare facility. As is the case with the rising cases of COVID-19, it would be near impossible for healthcare professionals to have the time to go and visit patients under the TCM program all the time. 

Video conferencing and phone consultations are used to check in with patients, share patient education, and answer questions in real-time. During virtual visits, the family’s caregiver, along with a medically certified interpreter or multiple care team participants, can be included. This will ensure alignment on the next phase in the continuum of care.


Patients from all over the country have benefited a lot from transitional care management programs. They have prevented many sudden hospitalizations and have improved patients’ quality of life as they transition into a home setting. Combined with telehealth, TCM has become a much more effective and valuable form of health service both for medical professionals and their patients.

Whether your patient has chronic conditions, behavioral health conditions, or just needs help transitioning out of an inpatient facility, Medistics is there to simplify their experience. Our dedicated care managers are always ready to help you get the support you need. If you need assistance with transitional care, do not hesitate to call us. Get in touch with Medistics Health today to get started.

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