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
“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.
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
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