Transitional Care Management (TCM) Solution for Better Patient Outcomes

Our team focuses on improving patient satisfaction, reducing costs, and ensuring seamless continuity of care through transitional care management (TCM) programs. By leveraging CMS transitional care management guidelines and best practices, our services bridge the gap between hospital discharge and community care.

Services We Provide

CareIQ’s transitional care management services are tailored to meet the needs of patients with moderate to high medical decision complexity. We coordinate care through three core components:

1. Initial Contact Within Two Business Days – After a patient’s discharge from a hospital or skilled nursing facility, our clinical staff makes interactive contact with the patient within two business days. This initial engagement ensures that patients understand their discharge instructions, medication changes, and upcoming follow-up visits. Timely contact also allows healthcare professionals to identify any immediate risks and provide necessary support.
2. Comprehensive Face-to-Face Visit Within Seven Days – A critical part of transitional care management CPT compliance is the face-to-face visit with a physician, nurse practitioner, or physician assistant within seven days of discharge. During this visit, our clinicians conduct medicine reconciliation, assess the patient’s status, and coordinate care management services to ensure a smooth transition back into the community. This step is crucial for both patient safety and improving outcomes.
3. Coordination of Follow-Up Visits and Community Resources – Scheduling follow-up visits and connecting patients with community resources is an essential component of TCM. Our team ensures patients have timely access to primary care providers, specialists, rehabilitation programs, and support services. By addressing social determinants of health and facilitating access to health resources, we reduce the risk of readmissions and enhance overall well-being.
4. High-Quality Documentation and Billing Support – CareIQ provides thorough documentation following current procedural terminology (CPT) codes for transitional care management services, including two CPT codes where applicable. Our clinical staff accurately record medical decision-making, complexity levels (moderate or high medical decision complexity), and all face visits to ensure proper CMS transitional care management compliance and billing.
5. Patient Education and Support – Education is a core part of transitional care management TCM. Our team works with patients and their families to provide guidance on medications, lifestyle adjustments, and warning signs that may require prompt medical attention. These efforts improve patient satisfaction and encourage better care across community settings.

Why Choose CareIQ’s Transitional Care Management Services

At CareIQ, we understand that smooth transitions from hospital to home or community care can make a significant difference in patient outcomes. Our transitional care management services stand out because we:

• Reduce Costs While Improving Outcomes: By coordinating care and preventing unnecessary hospital readmissions, our TCM services help reduce overall healthcare costs. Studies have shown that effective transitional care leads to better clinical outcomes while lowering financial burdens for both patients and healthcare systems.
• Enhance Patient Satisfaction: Our structured approach ensures patients feel supported, informed, and confident after discharge. Face-to-face visits, timely follow-up, and personalized care planning all contribute to higher patient satisfaction scores.
• Support Healthcare Professionals: Family physicians, nurses, and clinical staff rely on CareIQ for transitional care management services that streamline workflows, document care accurately, and maintain compliance with CMS TCM guidelines. Our programs reduce administrative burdens while ensuring better care for patients.
• Improve Community-Based Care Integration: We connect patients with local healthcare providers, rehabilitation programs, and community-based support systems to facilitate seamless transitions from hospital to home. Our care management services emphasize continuity, safety, and access to essential health resources.
• Expertise in CMS Guidelines and CPT Codes: Our team stays up to date with transitional care management CMS requirements, including TCM services, transitional care management CPT, and current procedural terminology (CPT) codes. Accurate documentation and billing help providers maximize reimbursement and maintain compliance.

About CareIQ

CareIQ is committed to delivering high-quality transitional care management services to patients and healthcare providers across the United States. Our team of clinical staff and healthcare professionals ensures safe, effective, and patient-centered care during the critical post-discharge period.

We focus on:

• Reducing costs for patients and healthcare systems
• Improving outcomes through structured TCM programs
• Enhancing patient satisfaction and engagement
• Supporting family physicians and clinical staff with compliant TCM documentation

By combining technology, experience, and community-based resources, CareIQ delivers transitional care management TCM services that make a real difference for patients and healthcare providers alike.

FAQs About Transitional Care Management