Transitional Care Management

By automatically receiving real-time discharge notifications, your practice can reach out to patients to ensure a smooth transition between care settings and eliminate gaps in care.

Eliminate gaps in care with automatic discharge notifications

When patients are discharged or transition between care settings, ChronicCareIQ automatically keeps tabs on them for the first 180 days to prevent readmissions, avoid complications, and automatically track the activities necessary for proper and optimized reimbursement.

With ChronicCareIQ, you receive real-time discharge notifications that allow your staff to proactively reach patients and other care providers in a timely manner, avoid gaps in care and stay connected.

Plus, your practice gets reimbursed for all of the extra time and effort your staff spends on helping to coordinate the transition of your medically complex patients who are at risk of complications.

Top Benefits of TCM

TCM office visits are reimbursed at twice the rate of regular office visits
Strengthen patient relationships as they transition between care settings
Proactively alert care management staff when enrolled patients change care settings
Ensure patients get the help they need during care transitions

“Our participation in value-based payment models continues to grow as a percentage of our revenue. ChronicCareIQ helps us ensure we hit all of the quality measures that are important to both our reimbursement rates and our patients.”

Primary Care Physician, Hospital-Owned Physician Group

How ChronicCareIQ Simplifies TCM

With ChronicCareIQ, your staff is notified through an automatic alert whenever an enrolled patient transitions to a different care setting.

They are able to proactively reach out to the patient, caregivers, and care providers via smartphone app, text, email, desktop or tablet to exchange information, documentation, and other insights that ensure a seamless transition.

Integrated with your EHR and phone systems, ChronicCareIQ automatically captures the data and timestamps needed to bill accurately and properly for the TCM reimbursement.

Everything you need to know about maximizing CPT billing

Want to know the ins and outs of new opportunities to boost reimbursements for 2025? Which CPT codes are extensions of others, and which aren’t combinable? How about which programs are affected by the recent elimination of time-based thresholds?

It’s all here in ChronicCareIQ’s comprehensive CPT Billing Code resource guide.

Hear What Our Customers are Saying

ChronicCareIQ has helped tremendously in keeping in touch with our patients on a constant and recurrent basis. It has also helped us improve our quality scores, decrease our emergency room utilization, and also decrease hospitalizations.

Doctors are not going to be able to live without ChronicCareIQ. The convenience and regular contact with patients is the big key going forward.

As a healthcare provider committed to delivering the highest quality of care, ChronicCareIQ has become an indispensable ally in our mission. The platform's impact on patient outcomes, from reducing hospital admissions to enhancing communication and achieving financial success, has exceeded our expectations.

I’ve really been pleased with our patient retention rate with ChronicCareIQ. Patients are very thankful for it and want to continue using it.

At Chesapeake & Washington Heart Care, we've seen remarkable improvements with ChronicCareIQ. It has greatly enhanced the efficiency of our phone interactions and the promptness in updating patient care. This has been vital in providing timely and effective healthcare services to our patients.

With ChronicCareIQ, we are better in touch with our patients, and patients feel better knowing that they have daily or regular contact with our office. We have also seen a significant decrease in office call volume.