Transitional (TCM) and Chronic Care Management (CCM)
The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals as well as reduced spending.
Medicare introduced the Transition of Care Management codes (TCM) to address the period of hand-off between acute care and the outpatient setting. Designed to improve the patient’s coordination of hand-off between facility and home, they will also benefit the physician and local hospitals.
In addition to TCM, on January 1, 2015, Medicare introduced the Chronic Care Management (CCM) program for non-face-to-face care coordination services furnished to beneficiaries with multiple chronic conditions.
Recognizing that patients with multiple chronic conditions are vulnerable to avoidable ED visits and admissions, Medicare expects this service to reduce healthcare expenditures and improve the coordination of care for chronically ill patients.
The majority of commercial payors have followed suit, recognizing the value of such programs in reducing readmissions, avoidable ED visits, and compliance with plan of care.
Medicare introduced the Transition of Care Management codes (TCM) to address the period of hand-off between acute care and the outpatient setting. Designed to improve the patient’s coordination of hand-off between facility and home, they will also benefit the physician and local hospitals.
In addition to TCM, on January 1, 2015, Medicare introduced the Chronic Care Management (CCM) program for non-face-to-face care coordination services furnished to beneficiaries with multiple chronic conditions.
Recognizing that patients with multiple chronic conditions are vulnerable to avoidable ED visits and admissions, Medicare expects this service to reduce healthcare expenditures and improve the coordination of care for chronically ill patients.
The majority of commercial payors have followed suit, recognizing the value of such programs in reducing readmissions, avoidable ED visits, and compliance with plan of care.
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Transitional Care Management (TCM) We understand that patients are very vulnerable to complications, unnecessary ED visits and readmissions during the immediate post-discharge time. We engage patients at a key point in their discharge process to focus on key risk factors. |
Our TCM program is designed to: Improve outcomes Provide supportive education Support the relationship between patients and physicians Reduce avoidable ED visits and readmissions Coordinate care between providers Minimize disruptions to current office workflows |
TCM program services include:
Licensed nurses with extensive acute and post-acute care experience Disease/medication specific education and reinforcement
“Warning signs” education
Patient empowerment
Provide patient and family with information on additional resources available
7/14 day appointment follow-up facilitation as appropriate to increase patient compliance
TCM-specific software with branching logic and risk assessment
Summary documentation that meets and exceeds CMS billing requirements
Licensed nurses with extensive acute and post-acute care experience Disease/medication specific education and reinforcement
“Warning signs” education
Patient empowerment
Provide patient and family with information on additional resources available
7/14 day appointment follow-up facilitation as appropriate to increase patient compliance
TCM-specific software with branching logic and risk assessment
Summary documentation that meets and exceeds CMS billing requirements
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Chronic Care Management Services (CCM) CMS recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for this vulnerable patient population. |
Our CCM program is designed to: Improve outcomes and the quality of care for chronically ill patients Empower patients to manage disease and improve compliance Coordinate care between providers Monitor patient progress |
CCM program design includes:
Acting as an extension of the physician
Management by experienced healthcare professionals Comprehensive tracking software
“Warning signs” Addressing/monitoring changes in medications
Coordination of care
Summary documentation that meets and exceeds CMS billing requirements
Acting as an extension of the physician
Management by experienced healthcare professionals Comprehensive tracking software
“Warning signs” Addressing/monitoring changes in medications
Coordination of care
Summary documentation that meets and exceeds CMS billing requirements
Physician Benefits Include:
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