Don’t Let Patients Slip Through the Cracks:
Why TCM + BettrAi Is the Bridge to Better Outcomes
Hospital discharge isn’t the end of care. It’s the beginning of one of the riskiest, most vulnerable periods in a patient’s journey—when they’re often left to manage recovery alone. And far too many don’t make it far before returning to the hospital.
In 2020, there were 3.8 million adult 30-day readmissions in the U.S., with an average cost of $16,300 per readmission — and nearly $27,400 for Medicare patients. These readmissions aren’t just expensive; they’re often preventable.
If you’re in the business of better patient outcomes—or driving performance in value-based care—you can’t afford to leave transitions unmanaged.
That’s where Transitional Care Management (TCM) comes in. And when you combine it with BettrAi’s AI-powered care platform and virtual assistant Sophie, you don’t just manage care transitions. You master them.
The Financial Stakes Are Real. So Are the Opportunities.
Since 2013, CMS has reimbursed for TCM services under CPT codes 99495 and 99496, recognizing the critical role that follow-up plays in preventing avoidable readmissions. But this isn’t just about reimbursement. It’s about results.
- A JAMA study showed that TCM-billed visits were linked to a 22% lower 30-day readmission rate compared to standard follow-up.
- In one organization that implemented a structured TCM strategy, 30-day readmissions dropped from 11.9% to 8.3%, and 90-day readmissions fell from 22.5% to 16.7%.
These are the kinds of improvements that avoid Hospital Readmissions Reduction Program (HRRP) penalties and lift HEDIS performance scores.
If you’re in a value-based contract—or just trying to control leakage and keep patients in-network—the return on investment is undeniable. But the “how” is everything.
What Makes TCM Work? (Hint: It’s Not Just a Follow-Up Call)
Let’s be honest. TCM only delivers results when it’sstructured, timely, and data-driven. CMS defines a clear set of criteria:
- Patient contact within 2 business days of discharge
- A face-to-face or telehealth visit within 7–14 days
- Medication reconciliation before or during the visit
- Ongoing care coordination for 29 days post-discharge
That’s a lot of touchpoints—and a lot of risk if they’re missed.
This Is Where BettrAi Steps In
Imagine a world where every TCM step is coordinated across settings, automated where appropriate, and monitored by both humans and intelligent software. That’s what BettrAi makes possible.
Before Discharge
- High-risk patients are identified
- Discharge plans are personalized
- Patients are introduced to Sophie, our multilingual virtual assistant
- RPM or CCM enrollment is offered based on need
- The patient is added to BettrAi’s ecosystem—no paperwork, no faxes
Day of Discharge
- Discharge date is logged automatically
- A follow-up appointment is scheduled within your network
- Sophie begins daily medication, appointment, and symptom reminders
- Other 30-day period tasks are auto-populated into the platform
Post-Discharge
- Centralized care teams monitor vitals, symptoms, and alerts in real-time
- Community-based PCPs reinforce care plans and communicate with the care team
- Sophie continues patient engagement, escalating alerts when needed
Everything is integrated. Documented. Actionable.
That’s how you reduce avoidable readmissions.
Why It Works: BettrAi Isn’t Just a Tech Tool—It’s a Care Partner
You’re not just adding another app to your workflow. You’re getting a full care coordination system that:
- Automatically initiates TCM workflows
- Sends multilingual messages via Sophie
- Triggers real-time alerts based on patient responses
- Coordinates care across centralized teams and community clinics
- Documents everything — in a way that’s billing-ready and CMS-compliant
Imagine If Your Organization Could Achieve This…
What if your practice or network could cut 30-day readmissions by over 3 percentage points?
What if 90-day rehospitalizations dropped nearly 6 points?
What if your performance on value-based contracts improved while your patients felt more connected, supported, and informed?
Those results are real. And they’re achievable with TCM + BettrAi.
Final Thought: Stop Talking About Readmissions. Start Preventing Them.
Every readmission you prevent is a win—for your patient, your team, and your bottom line. But that takes more than good intentions. It takes:
- A structured TCM process
- A platform that automates the right touchpoints
- A communication system that keeps everyone connected
- A partner like BettrAi that makes it easy to do all of the above—at scale
Because every day a patient stays well is a win.
Let’s make sure they don’t come back tomorrow for something we could have prevented today.