Background on Transitional Care Management (TCM):

Medicare began the TCM program in 2013 to incentivize better care for recently discharged hospital patients. The goal: to reduce readmissions, overall healthcare costs and improve health. 

Although the program has been proven to reduce costs $325 per discharge (p<0.001) and reduce mortality by 37.5% (p<0.001), only 7% of eligible patients received CCM in 2018.

Given busy clinical staff’s limited bandwidth and hiring challenges, this is no surprise. It’s not easy to coordinate below TCM requirements, on top of existing responsibilities:

  • Follow up call to review discharge instructions, medication changes & upcoming appointments (within 30 days of discharge)
  •  In office TCM appointment with provider (within 7 or 14 days, depending on complexity)
  • For more TCM requirements, scroll to bottom of article

Chronic Care Management: TCM’s Secret Weapon

Despite the challenges this imposes on busy clinical staff, there’s good news: We’ve seen Chronic Care management (CCM), an additional care management reimbursement/service, reinforce TCM programs at our practice partners. (Note: CCM can be billed concurrently with TCM.)

Indeed, a high-quality CCM program supports TCM programs by scheduling follow up appointments with PCPs or specialists, reinforcing medication and discharge plan adherence, and much more.

At CircleLink Health, our tele-RN’s leverage their ongoing, trusted relationship with CCM patients to enhance TCM in a variety of ways:

  • Customized TCM workflows. Here, CircleLink CircleLink tele-RNs do post-discharge TCM follow-up for CCM patients per our clinic partners’ specifications. This includes medication reconciliation, discharge instruction review and follow-up visit scheduling.
  • Prevention of hospitalizations altogether via monthly CCM calls. Since CCM’s goal is to prevent hospital admissions in the first place, CircleLink RNs do so in a number of ways, including guidance on improved diet (DASH Diet, low salt diet or anti-inflammatory diet) and connecting patients to resources like medication affordability programs, transportation services, mental health support and, finally, wellness groups like Silver Sneakers. CircleLink’s platform + tele-RNs are proven to reduce in-patient healthcare costs 62% vs. a risk-matched cohort (p = 0.004).
  • Risk-dependent follow-up calls. At a hospital-owned clinic partner, the hospital’s TCM team assigns patients a risk score dependent on factors such as reason for admission and social determinants of health. Then, depending on this risk score, CircleLink RNs provide additional, more frequent, follow up calls in addition to their normally scheduled CCM calls.
  • Clinics refer chronically hospitalized patients to the CCM program. Our partners will often send CircleLink a list of high-utilizers. CircleLink then enrolls those patients into CCM. Indeed, CircleLink has great success with high-utilizers, having reduced ER visits, inpatient visits and 30-day unplanned readmissions by 83-100% for a hospital-owned clinic. (High utilizers defined as 3+ hospital admissions or 6+ ER visits during the study’s 12-month baseline period.)

TCM Requirements – The Details

TCM services can be provided under general supervision by Physicians and non-Physician Practitioners who are legally authorized/qualified to provide the services in the state where they practice (NPs, PAs, CNMs, CNSs).

TCM reimbursement can be applied to transitions including: Inpatient Acute Care Hospital, Inpatient Psychiatric Hospital, Long-Term Care Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility, Hospital outpatient observation or partial hospitalization, Partial hospitalization at a Community Mental Health Center.

How can I supercharge my TCM program with CCM?

Interested in hearing more about Care Management for TCM or other use cases at your practice? Drop us a line at or call 844-797-8424.