Transition of Care Overview:

 According to the Centers for Medicare and Medicaid Services (CMS), “care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year”.

In an effort to reduce unnecessary hospital readmissions, the Centers for Medicare and Medicaid (CMS) created CPT codes 99495 and 99496 to pay providers to help their patients navigate transitions from hospital to home.

Successful care transitions can improve outcomes and patient satisfaction, decrease costs, and ensure that patients understand how, when, and where to seek help.  But in order to be successful, care transitions require timely, accurate, and sufficient communication of clinical information between providers, so that downstream services can immediately assume responsibility for patient care.

The Opportunity:


TCM spending.jpg

CMS estimates that two-thirds fo all discharges will be eligible for TCM services. Based on these estimates, CMS expects to spend over $1 billion annually on TCM services.  And while hospitals and physician practices can bill CMS directly for these services, they often don’t have the time or appropriate mix of staff to easily implement a TCM program and are inclined to partner with providers who can manage the 30-day care transition. 

This presents a new opportunity for a variety of care service providers. By providing outsourced TCM services, you can help patients avoid unnecessary re-hospitalization, help hospitals avoid readmission penalties and generate new revenue streams for your business.

 Getting started:

AviTracks-TC is designed to help you quickly implement your TCM services program and efficiently manage your patients through care transitions:

  • Implement a custom solution in days
  • No large upfront costs - just an extremely affordable monthly subscription
  • Subscription is based on number of patients, so you can start small and grow

See for yourself how easy it is to implement AviTracks-TC Transition of Care software - request a demo today!


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