Deliver proactive engagement to recently discharged patients to ensure care plans are being followed and health is improving.

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About Transitional Care Management (TCM)

TCM is designed for primary care doctors and specialists, as well as non-qualifying medical practitioners, for care they provide to patients who have been discharged from hospitals or other facilities or institutions as qualified by CMS.

Care Team Involved

  • Physicians (any specialty)
  • Non-physician practitioners (NPPs) who are legally authorized and qualified to provide the services in the State in which they are furnished: Nurse Practitioners, Physician assistants, Clinical nurse specialists, and Certified nurse-midwives
  • Have the option to embed a Peer Advocate or Certintell Health Coach to handle most of the patient-centered care through a shared care plan (Powered by Certintell)

  • An interactive contact must be made with the beneficiary and/or caregiver, as appropriate, within 2 business days following the beneficiary’s discharge to the community setting.

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  • As required by CMS, our solution goes beyond telephonic to cover all of your CCM needs; including asynchronous secure messaging, video calls, and Remote Patient Monitoring (RPM).

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  • You must furnish non-face-to-face services to the beneficiary, unless you determine that they are not medically indicated or needed.

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  • Required face-to-face visit must be furnished under a minimum of direct supervision and is subject to applicable State law, scope of practice, and the Medicare Physician Fee Schedule (PFS) “incident to” rules and regulations.

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