Transitional Care Management

Aligning care after hospitalization

The crucial 30-day period after discharge

Ineffective care transitions following hospitalization increase the rates and costs of hospital readmissions. The need for comprehensive care doesn’t end after hospital discharge. Many patients experience medication-related discrepancies, worsening their conditions, driving hospital readmission rates. In a value-based reimbursement environment, readmission rates may lead to CMS penalties which can threaten a hospital’s financial health.


At hospital admission or discharge, 7 out of 10 patients experience a medication discrepancy, and 1 out of 3 discrepancies cause patient harm


18-20% of Medicare patients are readmitted within 30 days of hospital discharge

$17 Billion

“Avoidable post-discharge hospital readmissions cost Medicare about $17 billion annually” (Source: The Center for Health Information and Analysis).


50% of readmitted patients were not seen by a provider in between discharge and readmission

“In fiscal year 2021, CMS will penalize 2,545 hospitals for having too many Medicare patients readmitted within 30 days of discharge

— Kaiser Health News.

PharmD Live’s Analytics-Driven TCM

Our turnkey solution integrates with healthcare organizations to efficiently support the seamless delivery of Transitional Care Management (TCM) services. These services include addressing social determinants of health (SDOH) to reduce readmissions and generate additional revenue while minimizing existing workflow disruptions.

Key features of our TCM program:

Additional Revenue Stream

TCM services are billable to Medicare with CPT codes 99495 and 99496.

Actionable Data and Auditable Reports

We generate standardized and audit-ready clinical and business intelligence reports which drive transitional care improvements, business decisions and enable compliance with CMS requirements.

Predictive Analytics

Our platform leverages predictive analytics to aggregate and analyze clinical and social determinants of health (SDOH) data from different sources that drive risk-stratification of patients and intervention customization.

EHR Integration and Customization

Our HIPAA-compliant telehealth platform seamlessly integrates with most EHRs and enables a bi-directional data flow and customizable TCM solution that is based on your patient population needs, organizational goals and metrics for success.

Remote Patient Monitoring

PharmD Live® maintains the continuity of care through remote physiological monitoring of discharged patients via device/wearable integrations to help patients continue their path to recovery while avoiding complications, medication discrepancies, and readmissions with the support of our 24/7 clinical pharmacist-led telehealth team.

24/7 Access to Clinical Pharmacists

Our clinical pharmacists contact patients within the first 48-hours of discharge to perform medication reconciliation. They facilitate the scheduling of face-to-face visits within 7 to 14 days with a PCP and perform high-touch patient follow-ups until day 30. Pharmacists are available 24/7 for patients and physicians.

Benefits of PharmD Live TCM


Additional Revenue Stream-TCM services are billable to Medicare with CPT codes 99495 and 99496


Improved quality measures – HEDIS, HCAHPS, MIPS/APMs


Avoid CMS penalties by reducing 30-day post-discharge hospital readmissions rate


Improved patient outcomes through enhanced care continuity and patient engagements


Compliance with CMS guidelines

We make it easy

Let Us Do All the Work

We prepare all TCM billing data reducing office paperwork.

Simplified Billing

We prepare all RPM billing data reducing office paperwork.

Automated Patient Eligibility

Our technology categorizes and identifies patients who are eligible for Transitional Care Management services maximizing enrollment.

Reduced Non-Billable Time

By shifting the TCM workload to our clinical pharmacists, your non-billable office time is vastly reduced.

Reclaim Your Time

Talk to one of our experts today.

2021 FDA-Approved Medications and Treatment Guidelines Update Webinar

Join our medication experts to learn about:
1. The newly approved medications for chronic diseases in 2021
2. Noteworthy changes in the disease treatment guidelines
3. And their impact on your patient population and quality measures

Wednesday November 17 @ 1pm EST
Last Chance to register!