Transition Care Management

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:

  • Review of discharge information
  • Appointment scheduling assistance
    • Face-to-Face with Physician within 7-14 days of discharge
  • Education and coaching
  • Follow up for additional appointments

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.



How We Measure Program Success



  • Savings to the hospital - reduced unnecessary re-admittances
  • Revenue to the physician
  • Identifies patients for CCM and/or PCM


  • Better long-term patient outcomes
  • Engagement with home-healthcare provider
    • Follow-up and oversight 
  • Continuous psychosocial review

Patient Engagement

  • Education and Coaching
  • Telephonic and electronic messaging
  • Medication assistance/reminders
  • Appointment reminders


  • Provider satisfaction
  • Cost to provider of acquiring patients
  • Revenues generated to provider

See Chronwell in action and schedule a demo with our team today.

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