Stronger transitions. Fewer readmissions.

TCM programs that close gaps after discharge and reduce avoidable utilization.

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Operational Outcomes & Program Impact

Operational Outcomes

Earlier risk detection outside visit windows
Fewer “unknowns” between check-ins
Better patient engagement without added staff time

Financial & Program Impact

Supports higher sustained enrollment
Improves documentation quality and continuity
Reduces staff follow-up overhead per patient

Where This Fits

Complements existing TCM workflows
No replacement of clinical decision-making
No billing interference or code dependency

Designed to strengthen programs already billing CMS-supported care management codes.

Who This Helps Most

Clinical Teams: Visibility into patient stability during the critical 30-day window
Operations: Automated transition tracking reduces missed follow-ups and scheduling gaps
Leadership: Reduced readmission penalties and stronger TCM program outcomes

What TCM Solves

TCM supports patients during the critical post-discharge period, ensuring timely follow-up, medication reconciliation, and care coordination.

30 days

Critical window after hospital discharge

1 in 5

Medicare patients readmitted within 30 days

75%

of readmissions are potentially preventable

How StillWell Health Supports TCM

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Post-Discharge Outreach

Structured contact within 2 business days of discharge.

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Follow-Up Coordination

Ensuring timely visits within 7 or 14 days per CMS requirements.

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Medication Reconciliation

Identifying and resolving discharge medication issues.

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Documentation Support

Compliant time tracking and claims preparation.

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CCM/RPM Alignment

Smooth transition into ongoing care management programs.

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Outcome Tracking

Monitor readmission rates and program effectiveness.

Who This Is For

Practices Managing Hospital Discharges

Primary care practices receiving patients back from inpatient stays.

Clinics Focused on Readmission Reduction

Organizations with quality metrics tied to hospital utilization.

Health Systems

Coordinating transitions across acute and ambulatory settings.

Platform Capabilities

Analytics & Reporting

Track readmission rates and TCM program effectiveness.

View Analytics → 🔗

EHR Integrations

Connect discharge data with care coordination workflows.

Learn More → 📅

Chronic Care Management

Transition TCM patients into ongoing coordination.

Explore CCM →

Ready to strengthen your transition workflows?

Let's discuss how TCM fits your discharge management and care coordination needs.

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