Transitional Care Management
Purpose Built
Launching a Comprehensive TCM Program for Health Information Exchanges
What is TCM and Why Does it Matter?
Transitional Care Management (TCM) services is a critical healthcare service designed to support patients transitioning from an acute care setting, such as a hospital, back to their community or home. TCM ensures continuity of care, reduces hospital readmissions, and enhances patient satisfaction, plus brings in more reimbursement from the federal government (Centers for Medicare and Medicaid Services). This program is especially vital for patients with chronic or complex conditions who are at higher risk of complications.
The benefits of a robust TCM program are multifaceted:
CrossTx: A Turnkey TCM Solution for HIEs
By implementing a TCM program with CrossTx, HIEs can drive transformative improvements in health outcomes, reduce costs, and capture significant reimbursement potential while ensuring compliance and operational efficiency.
Quality Improvement
TCM can significantly boost quality scores by reducing preventable readmissions and improving patient outcomes.
Patient Satisfaction
Timely follow-ups, comprehensive care coordination, and proactive communication improve patient experience and trust.
Financial Incentives
TCM services are reimbursable under CMS guidelines, offering substantial revenue potential for healthcare organizations.
CrossTx Solution
Why a Cloud-Hosted TCM Solution is Valuable for HIE Ecosystems
A cloud-based TCM solution offers HIEs a scalable and efficient way to standardize transitional care across their ecosystem. By leveraging a platform like CrossTx, HIEs can integrate purpose-developed TCM workflows with CMS compliance requirements, enabling seamless coordination between providers and reducing administrative burdens.
Key advantages of a cloud-hosted solution include:
Centralized Access
Providers across the HIE ecosystem can collaborate and access patient data in real-time.
Security & Compliance Assurance
Built-in workflows ensure adherence to CMS regulations, minimizing risks of non-compliance.
Enhanced Support
CrossTx offers not only software but also staffing solutions such as a centralized call center and nursing and administrative personnel, making it a turnkey offering.
Financial Potential
In regions with large patient populations, TCM reimbursements can grow into the hundreds of millions annually. Even in rural or frontier areas, these programs have the potential to transform care delivery and health outcomes across entire regions.
Guided Setup
Phased Deployment of a TCM Program
A successful TCM program for an HIE requires a structured, phased approach to ensure alignment, measurable results, and scalability. Below is the recommended three-phase rollout:
Phase 1: Planning and Stakeholder Alignment
- Objective: Establish the foundation for a unified TCM initiative across the HIE ecosystem.
- Actions:
- Align stakeholders, including hospitals, clinics, and other care providers, to define shared goals.
- Create governance structures with clear roles and responsibilities.
- Establish contracts with service level agreements (SLAs) and key performance indicator (KPI) targets.
- Conduct a readiness assessment to identify gaps and opportunities for each participating organization.
Phase 2: Early Adopter Rollout
- Objective: Demonstrate the program’s effectiveness with a pilot group of stakeholders.
- Actions:
- Deploy the TCM program to a subset of engaged providers or regions within the HIE.
- Focus on measurable outcomes, such as reducing hospital readmission rates and improving patient follow-up adherence.
- Use data insights to refine workflows and address any operational challenges.
- Share pilot successes to build momentum and buy-in across the ecosystem.
Phase 3: Full-Scale Implementation
- Objective: Scale the TCM program to all participants within the HIE.
- Actions:
- Roll out the program across the HIE patient catchment regions, leveraging lessons learned from the pilot phase.
- Provide ongoing training and support to ensure consistent adoption and performance.
- Monitor KPIs and quality metrics, using data to continuously optimize the program.
What They’re Saying
Testimonials
Kathy McQuade, RN, MSN
Carlinville Area Hospital
“CrossTx makes it easy to use, document, and track my chronic care patients. I am able to enter information related to patient care and print reports so that I know where I need to focus my time or efforts. The ability to include community resources and family members has helped gain better knowledge of patient conditions so that improved care is provided.”
Elizabeth Miller, CFO
Haskell Memorial Hospital
“Haskell Memorial is excited to be a part of the ongoing transition to Value-Based Care with utilizing our current staff members in Chronic Care Management, Transition of Care Management and other service lines. We are determined to continue improving the lives of our patients with measurable outcomes of success.”
Ella Helms, CEO
Cogdell Memorial Hospital
“The dedicated team’s process developed the Cogdell CCM Program infrastructure necessary to create an ideal system from the ground up. Appropriate resources were engaged, while eliminating any technological or workflow burdens from our providers. We will generate new revenue with increased patient engagement. Our team is committed to effective care for our Medicare Beneficiary population with multiple comorbidities.”
Nicole Talbert, RN
Samaritan Healthcare
“We began our care coordination program with a small grant. The CrossTx platform helped us track and report auditable and accurate numbers for the grant, as well as receive significant reimbursements for Medicare Chronic Condition Management, leading to sustainability for our care coordination program. With CrossTx, we are able to accurately report on results to a grantee and generate significant reimbursement for Chronic Care Management with the same platform.”
Margo Flores
Cobre Valley Regional Medical Center
“Working with the CrossTx platform gives us a compelling platform to communicate across various groups and teams resulting in a seamless, coordinated and holistic patient care. The CrossTx platform tracks all of our patient encounters and the associated time spent with each patient so billing at the end of the month is a breeze. The CrossTx platform helps us provide extraordinary care for our Medicare patients while maximizing our reimbursement from our care coordination program.”
Jeri Slover, RN
Hot Springs County Memorial Hospital
“I recently took over a Medicare chronic condition management program for this hospital involving five clinics. I have found the CrossTx platform to be very intuitive and easy to use. The software product has directly supported my jumping right into caring for our patients rather than spending time trying to learn a difficult to use piece of software.”
Request Demo
Learn how you can boost care coordination for at risk patients and immediately start boosting revenues.