Patients who come out of confinement often require follow-up care. In light of this, it paved the way for the Transitional Care Management (TCM) concept. TCM is for doctors, specialists, and non-qualifying medical practitioners to provide care to patients who have been discharged from hospitals or other CMS (Centers for Medicare & Medicaid Services) qualified facilities. 

This concept is designed to last 30 days that involves doctors engaging in face-to-face visits along with other types of meetings by phone or video call. With TCM, it helps ensure that there are no gaps in patient care. However, not all patients confined are qualified for the service. 

Qualifications for TCM

Before getting into TCM, only specific categories of healthcare professionals are qualified to provide and bill the service, such as physicians of any specialty, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physicians’ assistants. 

The use of Electronic Health Records (EHR) application is needed to qualify for TCM’s CMS reimbursements. 

The service requires healthcare professionals to make initial contact with patients within 48 hours after discharge. The face-to-face visit must then be done within one to two weeks following the release of the patient. 

Eligible Patients

Patients must be discharged from a qualifying service, such as skilled nursing facilities, hospital outpatient observation, long-term care hospitals, or inpatient psychiatric hospitals. In other words, patients who have chronic conditions, such as heart disease are eligible for TCM. 

Successful TCM Outcomes

For a service to be successful, care managers must create the discharge plan at the time of admission by knowing and understanding the treatment plan at home or length of hospitalization. Moreover, the manager must keep track of the patient’s health while admitted by learning about medications and teaching caregivers about it, especially if new meds are given. Likewise, managers should maintain clear communication with caregivers or the people that the patient will be at home with when it comes to ensuring that the medication plan is carried out. 

If you plan to provide TCM, you can invest in a remote patient monitoring system that will make processes go smoothly. With this medical device, you can view the results of the patients’ tests taken at home, such as blood pressure, glucose, or weight/BMI. With such information, you can streamline processes and provide excellent patient care. 


Transitional care management is essential for monitoring and managing chronic conditions. It helps ensure that the patient’s needs are met during the transition from inpatient to outpatient care. Moreover, it will help reduce readmission or relapses that will save hospitals and other facilities time and money. 

If you are planning to provide TCM services, make sure that you read about the requirements along with the provisions that come with the service. Having the right team of people is crucial to make the management go smoothly. You should also consider investing in tools that will help you streamline processes and provide more efficient patient care for your TCM services. 

The transition period between the time the patient is discharged and when routine care is re-established at home may be confusing for both patients and their loved ones. This is why the high demand for TCM to help everyone ease into the transition and provide better care that will make the patient’s recovery faster. 

With TCM, you get to ensure that your patients’ continuity of care will be beneficial not only for them but also for your practice and your facility. 

If you want to learn more about transitional care management, our team of experts will help simplify your experience. Having a patient-centered care mindset will help you deal with health problems effectively, at the right time, prevent complications and ensure a healthier future for all patients. Get in touch with us today to see how we can help!

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