Transitional Care Management (TCM)
A critical component of a High Performance Health Delivery Network Driving Reductions in Readmissions
Why Do Something? Why Now? Why BettrAi? Why prepare now for CMS TEAMS initiative that launches 1/1/26 ?
Did You Know:
Only 10-20% of potentially eligible patients receive Transitional Care
Management services.
Why the low percentages?
Due to barriers in provider identification, workflow integration, reimbursement issues, lack of standardized performance measures, and disparities in care delivery among diverse populations.
Did You Know:
Studies have shown that TCM
can significantly reduce the
risk of 30-day readmissions
compared to standard care,
with one study observing an
8.4% readmission rate for TCM
patients versus 13.9% for nonTCM patients
Did You Know:
78% of hospitals were assessed penalties under the Hospital Readmission Reduction Program (HRRP). TCM plays a significant role in reducing readmission. The maximum
HRRP penalty is 3%, which equates to $4.5m on average for a 300 bed hospital.
Did You Know:
The average 30-day all cause hospital readmission rate is 14.7% (with Medicare patients at 17%) and a cost of readmission at $15,000.
Studies show that TCM has delivered a 90-day savings
of $3,000-$4,000 per discharge.
Best Demonstrated Practice Hospital-led Transitional Care Management Programs
Studies Show:
- Significantly lower 30-day readmission rates (7.1%) compared to a control group (14.9%).
- Post-discharge outpatient TCM visits were associated with a 26% lower risk of 30-day readmission.
- Increased revenue for TCM reimbursement.
- $2m+ cost savings in readmissions for a 350 bed hospital.
- Lower 90-day mortality rates.
- Improved patient satisfaction and engagement while reducing gaps in care.
Why BettrAi?
BettrAi is uniquely qualified to support TCM programs with its 3 key TCM solutions:
Risk Stratification Platform
AI-driven Virtual Health Assistant
Unifying Care Management Platform
Critical interventions in the patient’s journey, to include: In-hospital: Medication reconciliation, patient and family education, and planning for post-acute care; Post-discharge: A home visit within 72 hours of discharge, followed by telephone check-ins for up to 90 days. This provided continued patient support and self-management coaching. Compliance, Tracking, measuring, reporting
Communication with Providers. The program standardized the timely sharing of discharge summaries with primary care physicians and specialists to ensure seamless care coordination. Screen for additional care management programs.
Risk stratification helps Transitional Care Management (TCM) by enabling providers to match resources and intensity of interventions to each patient’s specific needs. By systematically categorizing patients into risk levels, healthcare teams can proactively address potential problems and optimize care coordination, ultimately leading to better health outcomes and lower costs.
Proactive management of the more complex conditions such as CHF, COPD and pneumonia. These readmissions place a strain on hospital resources, negatively impact financial performance (HRRP) and lead to poor patient outcomes. Early identification of these patients is critical.
Multi-disciplinary teams: A “Complex Care Transition Team” (CCTT), consisting of a registered nurse case manager, a social worker, and a care management assistant, can effectively coordinate care from admission to 90 days post-discharge.
Focus on social determinants of health (SDoH) – more on genl sophie impact: The care team used SDoH questionnaires to address non-medical factors—such as housing instability or lack of transportation—that could affect patient recovery. Add more about tasks – scheduling etc
