Transition Care Management (TCM) includes medical services provided to a transitioning patient with medical and/or psychosocial problems from an inpatient facility to a community physicain.
The ChronWell TCM program focuses on the changeover from an inpatient facility stay to community physician setting. The program addresses the needs of the patient immediate after discharge and helps to align resources in order to properly transition them. This includes:
Transition Care Management can be billed concurrently with CCM services in the same month as an appropriate means of continuing the care beyond the inpatient facility for 30 days. It is also a key tool in reducing re-admissions.