Transitional Care Management
Transitional Care Management (TCM) provides intensive support for Medicare beneficiaries during the critical 30-day period following hospital discharge. Our platform facilitates required communication within 2 business days, schedules face-to-face visits within 7 or 14 days based on medical complexity, coordinates with discharge planners, reconciles medications, and ensures patients attend follow-up appointments to prevent costly readmissions.
Key benefits
Medicare TCM billing (99495, 99496)
Discharge summary import
Automated follow-up reminders
Medication reconciliation
Readmission risk analysis
40-50% readmission reduction
Essential capabilities
The main features included in this program.
Transitional Care Management
Support for patients transitioning from hospital to home, preventing readmissions and ensuring continuity of care.
Learn more →
EMR Integration
FHIR and HL7 integration with existing EMR/EHR systems for seamless data exchange.
Learn more →
Time Tracking & Compliance
Automated time tracking for Medicaid services ensuring accurate documentation for reimbursement.
Web-Based Platform
Cloud-based RPM software accessible from any device, designed specifically for home care workflows.
Provider Reporting
Comprehensive provider dashboards and performance reports for quality improvement and billing optimization.
All features (16)
The complete list of capabilities included in this program.
Care Team Collaboration
Shared notes, time tracking, and task automation for seamless care coordination.
Learn more → EMR Integration
FHIR and HL7 integration with existing EMR/EHR systems for seamless data exchange.
Learn more → Time Tracking & Compliance
Automated time tracking for Medicaid services ensuring accurate documentation for reimbursement.
Web-Based Platform
Cloud-based RPM software accessible from any device, designed specifically for home care workflows.
Audit-Ready Documentation
Comprehensive reporting and documentation that meets TMHP audit requirements for Medicaid billing.
Smart Multilingual Messaging
AI-powered multilingual communication that automatically translates messages to reach diverse patient populations.
HIPAA Secure Platform
Enterprise-grade security with full HIPAA compliance, end-to-end encryption, and regular security audits.
Patient Onboarding
Streamlined enrollment process with guided setup, device pairing assistance, and patient education materials.
Digital Consent Forms
Paperless consent management with electronic signatures, secure storage, and automated compliance tracking.
Medication Tracking & Reconciliation
Comprehensive medication management with adherence tracking, interaction alerts, and automated reconciliation.
Mobile Access
Full-featured mobile apps for iOS and Android enabling care teams to monitor and respond from anywhere.
Multi-Language Support
Support for 20+ languages including Spanish, Vietnamese, and other common patient languages.
Data Export Tools
Export patient data, billing reports, and compliance documentation in multiple formats (PDF, CSV, Excel).
Provider Reporting
Comprehensive provider dashboards and performance reports for quality improvement and billing optimization.
Redundancy
Cloud-based infrastructure with automatic backups and 99.9% uptime guarantee for reliable 24/7 access.
Transitional Care Management
Support for patients transitioning from hospital to home, preventing readmissions and ensuring continuity of care.
Learn more →How you get paid
Built for these providers
Primary Care Practices
Hospital-Based Care Teams
Post-Acute Care Providers
Accountable Care Organizations
Integrated Health Systems