Dr. Eun Ji Kim and her team at Northwell Health’s Feinstein Institutes for Medical Research set out to determine whether Transitional Care Management (TCM) services directly reduce 30-day hospital readmission rates—or if the benefit is driven by broader provider and clinic-level care improvements. TCM visits, reimbursed by CMS at higher rates than standard post-discharge follow-ups, require providers to contact patients within 48 hours of discharge and conduct a follow-up visit within two weeks. The study aims to clarify whether TCM visits themselves lower readmission rates or if simply being treated by a provider who regularly utilizes TCM results in better post-discharge outcomes.

Study Design

This large-scale, real-world analysis used data from Northwell Health, covering 11,391 adult patients discharged from February 2018 to February 2020. Researchers compared patients who received a formal TCM visit (billed under CPT codes 99495/99496) versus those who had non-TCM follow-up visits within two weeks of discharge.

They also analyzed whether patients seeing providers who frequently use TCM services had lower readmission risks—even if their specific visit wasn’t coded as TCM.

The primary outcome: unplanned hospital readmission within 30 days.

To ensure robust comparisons, researchers used propensity score matching (1:1 nearest neighbor) to control for variables like age, race, comorbidities, and time to follow-up. They then ran a Cox proportional hazard model to measure the relative risk of readmission between groups.

TCM Services Deliver a Significant Drop in Readmissions

1. TCM Visits Cut Readmissions by Nearly 40%

• 8.4% of TCM patients were readmitted within 30 days, versus 13.9% in the non-TCM group.
• This translates to a 26% lower readmission risk (HR = 0.74 [0.63–0.88], p<0.001).

2. The Provider Matters—Even If the Visit Isn’t TCM

• Patients who had non-TCM visits but were seen by a provider who frequently billed TCM visits had a 16% lower risk of readmission (HR = 0.84 [0.71–0.99]).
• However, simply being in a clinic that utilized TCM visits frequently—regardless of the specific provider—led to a 24% reduction in readmissions (HR = 0.76 [0.64–0.92]).

3. Why Does TCM Work? The 48-Hour Post-Discharge Contact Is Key

• The biggest difference between TCM and non-TCM follow-ups? Early post-discharge patient contact.
• The mandated 48-hour check-in likely helps flag post-hospital complications, ensuring quicker interventions before patients deteriorate.
• This direct outreach could explain why even non-TCM visits in TCM-heavy clinics saw reduced readmissions.

Patterns & Systemic Failures

So, if TCM is effective, why is it not standard practice?

Despite the proven benefits, TCM remains vastly underutilized. Many providers and clinics fail to use the billing codes or don’t implement the structured 48-hour follow-up.

• Are reimbursement structures too complex?
• Are providers unaware of the benefits?
• Are hospitals failing to enforce these processes?

Importantly the healthcare system rewards readmissions, not prevention.

The financial penalties for excessive readmissions under CMS’s Hospital Readmissions Reduction Program (HRRP) are far outweighed by the financial incentives hospitals receive from high patient turnover.

This creates a perverse system where hospitals may not aggressively implement TCM despite its effectiveness.

Moreover, post-discharge care coordination remains weak according to this latest entry in PLOS One.

This latest study suggests systemic failures in follow-up care. While TCM visits directly reduce readmissions, even patients receiving standard post-discharge care see some benefit if their provider or clinic frequently uses TCM services.

Along these lines this suggests that systemic changes—rather than just TCM visits themselves—are driving lower readmission rates.

What’s the bottom line from a CrossTx point of view?  Well-coordinated post-hospital care works. But many patients aren’t getting it.

Limitations & Open Questions

Like all studies this investigation included limitations.  First the study doesn’t capture out-of-network follow-ups, meaning some patients may have received TCM-level care elsewhere without being counted. Second variation in provider TCM use isn’t well understood. Why do some providers fully utilize TCM while others ignore it?

Finally, telehealth vs. in-person TCM matters. With post-pandemic virtual care surging, would remote TCM visits yield the same benefits?

TCM Works—But the Healthcare System Is Ignoring It

According to CrossTx VP of Client Success Chandra Donnell “the data is clear: TCM visits significantly lower hospital readmissions, and even non-TCM visits see benefits when providers or clinics prioritize structured follow-up care.”

Yet, despite this compelling evidence, healthcare systems are failing to fully implement TCM at scale. The barriers? Bureaucratic red tape, lack of financial incentives, and a reactive—not proactive—approach to post-hospital care.

If policymakers, payers, and health systems truly want to cut readmission rates and reduce preventable hospital stays, the answer is simple: mandate structured transitional care, fund it properly, and hold providers accountable for implementing it.

Until then, thousands of preventable readmissions will continue—and the broken system will keep profiting from it.

Daniel O’Connor
Chief Business Officer
CrossTx Inc.