Transitional Care Management

Take charge of the discharge for better care and lower cost.

A-man-sitting-in-a-chair-in-a-hospital-room-waiting-to-be-formally-discharged-from-the-hospital, representing Admission Discharge Transfer processes.
Smartlink TCM is part of our single platform solution for delivering Medicare’s Care Management programs and also includes CCM, AWV, and CoCM.

One of the best ways for healthcare providers to improve cost performance and
quality outcomes is to ensure patients experience a seamless transition from the hospital back to a community setting. Our Transitional Care Management (TCM) solution helps you provide TCM services as efficiently as possible, so you can provide the service to more of the patients that need it. It’s a triple win for patients, hospitals, and primary care providers.

Tracking at a Glance

Visualize the status of all TCM patients

Simple Workflow

Manage patients receiving TCM services

Complete Audit Trail

Ensure compliance and get paid accurately

Transitional Care Management software by Smartlink Health displayed on a laptop screen.

Getting paid to coordinate post-discharge care makes sense in theory, but staying on top of Medicare’s scope of service requirements for one patient – let alone a population of patients – is challenging, at best. Smartlink TCM solves this challenge by managing the entire TCM workflow from beginning to end for all of a clinic’s TCM eligible patients.

  • Record and track all TCM activities against TCM requirements and ensure compliance for each patient

  • Count TCM activity time toward Chronic Care Management (CCM) billing in the event TCM is not billed

  • 100% CMS & HIPAA compliant

Integrate with Your EHR

Smartlink integrates with over 90 EHRs. Billable encounters can automatically be created in your EHR for TCM billable events.

Insert HIE Data Into the EHR

Automatically Recieve ADT Notifications from Your State HIE

Eliminate the manual effort of checking hospital portals or the HIE for ADTs. Smartlink TCM integrates with HIEs to automatically receive ADT notifications along with the associated patient records. The TCM encounter is prepopulated with the information received, so your staff can focus on taking care of patients instead of data management.

Leverage One Single Platform for Five Medicare Programs.

Provide Medicare’s AWV, CCM, BHI, CoCM and TCM to patients from a single, comprehensive modular platform. The system can be used in part or whole, so you can start with one program and implement additional ones as needed and when ready.

Providers

A father holding his daughter during a telehealth visit with a doctor.

Proactively care for your patients while creating a new revenue stream for the practice.

Service Providers

A father holding his daughter during a telehealth visit with a doctor.

Maintain a high level of productivity and customer satisfaction as you grow.

ACOs

A father holding his daughter during a telehealth visit with a doctor.

Support your member providers in reducing the cost of care for attributed patients.