Transitional Care Management

The crucial 30-day period post-discharge

Ineffective care transitions following hospitalization contribute to higher rates and costs of hospital readmissions. The need for comprehensive care continues beyond hospital discharge. Many patients face medication-related discrepancies that worsen their conditions, increasing readmission rates. In a value-based reimbursement environment, these rates can result in CMS penalties, posing a financial risk to hospitals.

7/10

At hospital admission or discharge, 7 out of 10 patients experience a medication discrepancy, with 1 out of 3 discrepancies resulting in patient harm

18-20%

18-20% of Medicare patients are readmitted within 30 days of hospital discharge

$17 Billion

"Avoidable post-discharge hospital readmissions cost Medicare about $17 billion annually" (Source: The Center for Health Information and Analysis)

50%

50% of readmitted patients did not have a provider visit between discharge and readmission.

SimpleCare Medical Services' Analytics-Driven TCM

Our turnkey solution integrates with healthcare organizations to efficiently support the seamless delivery of Transitional Care Management (TCM) services. These services encompass addressing social determinants of health (SDOH) to reduce readmissions and generate additional revenue, all while minimizing existing workflow disruptions.

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Significant features of our TCM program

Additional revenue stream opportunities

TCM services are billable to Medicare.

Actionable data insights and auditable reports

We generate standardized and audit-ready clinical and business intelligence reports that drive improvements in transitional care, inform business decisions, and ensure compliance with CMS requirements.

Predictive Analytics

Our platform leverages predictive analytics to aggregate and analyze clinical and social determinants of health (SDOH) data from diverse sources. This drives risk stratification of patients and customization of interventions.

EHR Integration and Customization

Our HIPAA-compliant telehealth platform seamlessly integrates with most EHRs, facilitating bi-directional data flow and customizable TCM solutions tailored to your patient population needs, organizational goals, and success metrics.

Remote Patient Monitoring

SimpleCare Medical Services maintains continuity of care through remote physiological monitoring of discharged patients via device/wearable integrations. This helps patients continue their path to recovery, avoiding complications, medication discrepancies, and readmissions, supported by our clinical pharmacist-led telehealth team.

Availability to Clinical Pharmacists

Our clinical pharmacists initiate contact with patients within 48 hours of discharge to conduct medication reconciliation. They coordinate face-to-face visits with a primary care provider (PCP) within 7 to 14 days and provide high-touch patient follow-ups until day 30. Pharmacists are available to support both patients and physicians.

The SimpleCare Live Benefits

01

Additional Revenue Stream - TCM services are billable to Medicare using.

02

Avoid CMS penalties by reducing the 30-day post-discharge hospital readmission rate.

03

Improved quality measures – HEDIS, HCAHPS, MIPS/APMs.

04

Improved patient outcomes through enhanced care continuity and patient engagement.

05

Compliance with CMS guidelines

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We make it accessible

We handle the workload

Partnering with Simple Care Medical Services shifts the burden. Remote Patient Monitoring to us, enabling providers to optimize their practice time.

Streamlined billing

We manage all RPM billing data, reducing office paperwork.

Automated patient eligibility verification

Our technology categorizes and identifies eligible patients, maximizing enrollment in our services.

Decreased non-billable time

Partnering with Simple Care Medical Services shifts the responsibility of Remote Patient Monitoring to us, enabling providers to optimize their practice time.

Transitional Care Mangement