Close the Loop on Transitional Care.
Guideway’s TCM Activation offering is a fully at-risk model that complements our standard readmission program. Immediately after discharge, we contact patients to schedule the timely follow‑up visit required for Transitional Care Management billing. We coordinate any pre‑appointment tasks such as medication reconciliation, referral orders, and lab work, and then transition patients into the broader readmissions program for ongoing, non‑clinical support.
What We Do
- Proactively reach out within two business days to schedule the TCM appointment.
- Confirm that required services (med reconciliation, symptom assessment, referral coordination) are completed.
- Address logistical barriers to attending the TCM visit (transport, caregiver coordination).
- Handoff to Activation Care Guides for continued support and barrier resolution.
- Provide documentation to meet CMS TCM requirements.
Benefits
- Higher completion rates of TCM visits.
- Increased revenue capture under CMS’s TCM program.
- Reduced readmissions through prompt follow‑up.
- Smooth integration with existing Guideway activation workflows.
- Improved patient satisfaction during transitions of care.
