Transitional Care Management

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Risks & Costs associated with inpatient discharges

Transitions from inpatient healthcare to home community settings carry known risks to patient safety.

Readmission Rate
High Readmission Rates

Every year, nearly 1 in 5 Medicare patients is readmitted to the hospital within 30-days of discharge; over half of those did not have contact with their primary care provider after discharge, equating to 2.6 million seniors and costing the U.S. healthcare system over $26 billion. 

What Is Transitional Care Management?

Transitional Care Management (TCM) is a post-discharge service designed to provide physician-led, coordinated care to patients following an inpatient discharge to help reduce readmissions, improve health outcomes, and secure savings. 

Required TCM Services

  • Supporting the patient’s transition to the community setting
  • Health care professionals taking responsibility for patient’s care
  • Health care professionals who accept patient care at post-facility discharge without a service gap
  • Moderate or high complexity medical decision making for patients who have medical or psychosocial problems

TCM Service TimELINE

The Transitional Care Management period is 30-days. It begins on a patient's inpatient discharge date and continues for the next 29 days.

The inpatient or partial hospitalization setting must be one of these healthcare environments:

  • Inpatient Acute Care Hospital
  • Inpatient Psychiatric Hospital
  • Long-Term Care Hospital
  • Skilled Nursing Facility
  • Inpatient Rehabilitation Facility
  • Hospital outpatient observation or partial hospitalization
  • Partial hospitalization at a Community Mental Health Center

After inpatient discharge, the patient must return to their community setting. These could include:

  •  Home
  • Domiciliary
  • Nursing home
  • Assisted living facility

Approved TCM Providers

A face-to-face visit must be conducted by a physician or any approved Non-Physician Practitioner (NPP). These providers can also supervise auxiliary personnel, which includes clinical staff.

NPPs and auxiliary personnel may provide the non-face-to-face services of TCM under the general supervision of the physician or NPP subject to applicable state law, scope of practice, and the Medicare Physician Fee Schedule (PFS) “incident to” rules and regulations. 

Transitional Care Management  Benefits

Besides improving patient health outcomes and reducing readmission rates, utilizing the WLI team, the estimated net annual revenue for a 10-provider practice to complete transitional care management services for their patients $795,000.

Reduction in Readmission Rates; Better Patient HEalth Outcomes

Give patients peace of mind knowing their care is being managed as they transition and increase care plan compliance.

avoidance of readmission penalties

The goal is to improve the patient experience while saving health systems the cost of avoidable readmissions.

Improved Care Coordination with other providers

WLI assists your staff and facilitate care coordination among providers.

Sustain and Improve Profitability for Your Practice

Medicare provides billing codes to incorporate TCM services to compensate practices while improving patient care and reducing overall health care expenses.

Our Services


Here's what your patients can expect with Well Living Initiative TCM services. 

  • You and your patients will gain a team of dedicated health care professionals who can help patients plan for better health and stay on track after their hospital discharge.
  • Reduce hospital readmission by proactive communication.
  • The plan will help support their disease control and health management goals.


Here's what your practice can expect with Well Living Initiative TCM services. 

  • Improve care coordination with other providers.
  • Support patient compliance and help patients feel more connected.
  • Reduce readmission rates. A 10% readmission rate was reduced to a 2 - 3% readmission rate with the WLI TCM program.
  • Sustain and improve profitability for your practice. Offering WLI may provide you with increased profitability, improved patient care resulting in higher MIPS scores.
  • The medical office would NOT need to hire additional staff.
  • Fi-Med schedules the appointment, and handles all of the administration.
  • Appointments with WLI patients will run more efficiently and effectively as the physician will know of any patient concerns or issues prior to the start of the appointment.

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