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Coosa Care’s Transitional Care Management program is designed to bridge the gap from hospital to home, helping patients avoid readmissions while ensuring providers remain compliant and supported.

Smoother Transitions.
Better Outcomes.

Why TCM Matters?

  • Reduced Readmissions: TCM helps lower the likelihood of patients returning to the hospital after discharge, a common risk among Medicare beneficiaries.

  • Cost Savings: Fewer readmissions mean lower costs for providers and the healthcare system overall.

  • Patient Engagement: Continuous monitoring and timely follow-up keep patients healthier and more confident at home.

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How we benefit you

What Patients Can Expect

  • Early Contact: We reach out to patients within 2 business days of discharge.

  • Discharge Review: We walk through discharge summaries and instructions with patients and caregivers.

  • Care Coordination: We collaborate with other providers, specialists, and community resources to ensure continuity of care.

  • Ongoing Monitoring: Patients receive proactive follow-ups that identify risks before they escalate.

  1. Our process makes it easy for practices to stay compliant while giving patients peace of mind:

  2. Interactive Contact (within 48 hours): A call to confirm discharge details, identify needs, and begin care transition.

  3. Medication Reconciliation: Ensuring patients understand and follow updated prescriptions.

  4. Care Coordination: Communication with specialists, home health, or community services as needed.

  5. Face-to-Face Visit: Scheduled within the required timeframe (7 or 14 days, depending on complexity). Telehealth now qualifies to meet this requirement, giving patients greater access and flexibility.

  6. Ongoing Engagement: Continuous monitoring and follow-ups help prevent complications and reduce hospital readmissions.

The Coosa Care TCM Workflow

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  • Reduces Workload: Our services integrate into existing workflows without adding burden.

  • Ensures Compliance: Every step aligns with CMS guidelines, including face-to-face visit requirements.

  • Enhances Efficiency: Streamlined reminders, reconciliation, and reporting tools save time.

  • Improves Outcomes: Patients get the support they need to heal, providers gain peace of mind, and practices maintain strong quality scores.

How TCM Helps Providers

With Coosa Care’s Transitional Care Management, providers can reduce readmissions, protect revenue, and give patients the support they need — whether that face-to-face follow-up happens in the office or through Telehealth.

Discover how seamlessly we can fit into your practice.

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