Structured post-discharge contacts, med reconciliation, and appointment coordination to cut readmissions.
Patients are vulnerable to complications and readmission in the 30 days following hospital discharge. Transitional Care Management (TCM) supports them during this high‑risk period. PharmD Live®’s TCM program provides structured follow‑up and care coordination to ensure a safe return to the community.
Care managers reach out within two days of discharge.
Patients receive an in‑person or telehealth visit within seven days (high complexity) or 14 days (moderate complexity).
Pharmacists review medications to prevent interactions or duplications
Collaborate with specialists, community services and caregivers.
Provide self‑management support and address signs of worsening conditions.
Link patients to community resources and social services for additional support.
Document and bill TCM codes (99495 or 99496).
Structured follow‑up and medication reconciliation lower the risk of rehospitalization
TCM codes provide additional reimbursement for post‑discharge management, complementing CCM and APCM programs
TCM enhances adherence to care plans, reducing complications and supporting recovery.
Patients experience a seamless transition from inpatient to outpatient care, improving satisfaction and quality metrics.
Our TCM program leverages pharmacists, nurses and care coordinators to deliver comprehensive post‑discharge support. We integrate TCM with CCM and APCM modules for a unified approach. Our technology automates scheduling, documentation and billing, ensuring compliance and maximizing revenue. Patients receive the right support at the right time, reducing readmissions and sustaining value‑based performance.