Transition of Care Software


AviTracks-TC offers complete functionality for managing patients in care transitions. 

With AviTracks-TC you can automate your entire care transition workflow - from enrolling the patient, documenting medications, tracking phone calls and other care coordination activities, to generating reports needed for billing purposes. For providers participating in Medicare, this includes supporting documentation for CPT codes 99495 and 99496.




  • Enables team-based care and care coordination across providers
  • Set up multiple programs and protocols (TCM, CCM, AWV, etc.)
  • Create electronic care plans, assign teams and separate the tasks among physicians, nurses and coach coordinators
  • Create custom questionnaires for patient follow up
  • Record and log time for every interaction with the patient
  • Customizable workflow process
  • Risk profiler - assign a risk level to each patient and adjust tracking based on risk
  • Flag patients by condition, risk or program for easy identification and monitoring
  • Implement across multiple care provider teams, letting each group focus on their work and at the same time share critical information
  • Reports and statistics by user - administrators can see staff workload as well as identify highly efficient nurses, coaches and care coordinators
  • Create documentation for billing purposes including CMS CPT codes 99495 and 99496

System Architecture:

  • AviTracks-TC is a web based application
  • AviTracks-TC is offered as a Cloud SaaS solution (Software as a Service)
  • AviTracks-TC runs under encrypted technology (https) providing an extra layer of security

HIPAA Compliance and Security:

  • Microsoft Azure cloud hosted environment
  • Fully redundant data centers in the United States
  • HIPAA Compliant
  • Full Chain of Business Associate Agreements
  • Comprehensive suite of security technologies
  • Data fully encrypted during transit and at rest
  • Antivirus protection

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