TCMS Overview

  • Coordinates patient transitions across the care continuum
  • Manages transitions to multiple post-acute settings
  • Tracks all encounters, episodes and services
  • Manages hospital & home visits and follow-up calls
  • Enables collaboration on behalf of Patient across multiple IT Systems
  • HIPAA-compliant
  • Integrate w/ EMRs using HL7 v3 standards
  • Daily Automated notifications

Automated Data Collection and Reporting

  • Patient enrollment is integrated with I&A work-flow
  • Transitions Measures Forms (CTM-3, CTM-15)
  • CMS patient experience surveys (1st, 2nd Administration)
  • CMS monthly invoice and payment tracking
  • Track discharge instructions and patient medication lists
  • Transitional Care Management outcomes reporting