What is Transitional Care Management (TCM)?
Transitional Care Management (TCM) is a Medicare-covered service designed to support patients during the critical transition from an inpatient setting back to the community.
Following discharge from a hospital, skilled nursing facility (SNF), rehabilitation center, or other inpatient facility, patients face a high risks of complications, medication errors, and readmission. TCM services ensure structured, physician-led follow-up care during the first 30 days post-discharge, significantly improving outcomes.
TCM includes:
- Immediate post-discharge outreach
- Medication reconciliation
- Care coordination with all providers
- Timely physician evaluation
- Ongoing monitoring and escalation
Why TCM Matters (Clinical + Financial Impact) For Hospitals & Skilled Nursing Facilities
We help reduce readmissions by ensuring every discharged patient receives:
- Immediate follow-up
- Structured care coordination
- Physician-guided recovery
Partnership Benefits
- Improved discharge outcomes
- Reduced penalties
- No clinical burden on your staff
- Scalable post-discharge solution
- Revenue optimization
- Lower total cost of care
- Better utilization management
- Structured to align with federal healthcare guidelines
Compliance & Regulatory Alignment
Our TCM program is built to align with:
- CMS TCM requirements
- HIPAA (45 CFR Parts 160 & 164)
- Minimum Necessary Standard
- Medicare documentation guidelines
We maintain:
- Audit logs
- Communication records
- Time tracking
- Secure PHI handling
For Physicians & Medical Groups
We enable physicians to deliver TCM without operational burden.
You Get:
- Fully managed workflow
- Documentation support
- Compliance protection
You Maintain:
- Clinical control
- Patient relationship
- Better utilization management
- CMS-aligned care delivery
Who Qualifies for TCM Services?
Patients are eligible for TCM if they are discharged from:
- Acute care hospitals
- Skilled Nursing Facilities (SNFs)
- Inpatient rehabilitation facilities
- Long-term care hospitals
- Partial hospitalization programs
Patient Criteria
- Medicare beneficiary (traditional or Medicare Advantage)
- Discharged to home or community setting
- Requires moderate or high complexity medical decision-making
How the TCM Process Works
Discharge Event
Patient is discharged from a qualifying facility.
2-Day Contact Requirement
Within 2 business days, a licensed clinical team member:
- Contacts patient (phone, video, or in-person)
- Assesses condition and needs
- Initiates care coordination
Medication Reconciliation
- Full review of discharge medications vs. prior regimen
- Identification of discrepancies or risks
Care Coordination
- Communication with PCP, specialists, home health, pharmacies
- Scheduling follow-ups and services
Physician Evaluation (Face-to-Face or Telehealth)
- Within 7 days (high complexity) OR
- Within 14 days (moderate complexity)
30-Day Management Period
Ongoing:
- Monitoring
- Patient communication
- Escalation of issues
- Documentation
Our Model at Elite Prime Care, Inc.
Elite Prime Care, Inc. operates as a Management Services Organization (MSO) supporting physician-led TCM services in full compliance with:
- CMS guidelines
- HIPAA regulations
We Provide:
- Administrative infrastructure
- Care coordination support
- Patient outreach systems
- Documentation workflows
- Audit-ready compliance systems
- Technology & reporting
Physician Responsibilities:
- Establish medical necessity
- Perform required evaluation
- Oversee care plan
- Bill under their NPI
What Makes Our TCM Program Different
Audit-Ready from Day One
Every interaction is:
- Time-stamped
- Documented
- CMS-compliant
Physician-Centered Model
We do NOT interfere with clinical decision-making — we support it.
Rapid Deployment
We can operationalize TCM programs quickly for:
- Hospitals
- SNFs
- Post-Acute and Rehab Centers
- Physician groups
Integrated Care Approach
Optional integration with:
- Remote Patient Monitoring (RPM)
- Chronic Care Management (CCM)
- Behavioral Health Integration (BHI)
Frequently Asked Questions
Get Started with TCM
Whether you are:
- A hospital looking to reduce readmissions
- A SNF improving discharge outcomes
- A physician seeking additional revenue streams
- Elite Prime Care, Inc. provides a turnkey, compliant, and scalable TCM solution.