TCM
Transitional Care Management
Transitional Care Management supports patients during the period after discharge from a qualifying inpatient or facility setting—coordinating outreach, medication questions, and follow-up with the practice. It is episodic, not a continuous monthly service.
Assess TCM for your organizationScoped workflow
How TCM works
Illustrative workflow. Specific responsibilities are agreed with each organization.
- 01
Identify transition
Discharges are identified through the data sources agreed with the practice.
- 02
Outreach
The patient or caregiver is contacted according to the agreed protocol.
- 03
Medications
Medication questions are gathered for reconciliation by the responsible clinician.
- 04
Coordinate visit
Follow-up with the practitioner is scheduled and supported.
- 05
Escalate & document
Concerns are escalated and interactions documented.
Program considerations
Identifying transitions
TCM depends on knowing when a patient is discharged. How transitions are identified—and what data is available—is one of the first things reviewed during scoping.
Timing requirements
TCM carries specific timing and documentation requirements. These are reviewed against current, dated guidance during implementation rather than summarized here.
Implementation, documentation, and coverage
Implementation steps, documentation standards, and reporting formats are agreed during scoping. Coverage and reimbursement vary by payer, patient, service, documentation, and applicable requirements.
Common questions
Does Kare perform the TCM visit?
The required face-to-face visit and medical decision-making are performed by the practitioner. Kare's supporting role is defined during scoping.
Is TCM right for your patients?
Discuss program fit, responsibilities, and implementation with Kare.