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Supporting Patients from Hospital to Home with Transitional Care Management (TCM) and CipherOutreach

TCM Blog

Transitional care management (TCM) programs are designed to help patients make a smooth transition from the hospital to home or another care setting. This can be a vulnerable time for patients, with the potential for negative health outcomes and higher health care costs. TCM programs work to ensure the patient’s needs are well-managed during this time so they can recover, stay healthy and avoid hospital readmission.

With TCM, providers in eligible care settings can receive reimbursements per patient by meeting program requirements.  Specifically, health systems must initially engage with patients within two days of their discharge and document this interaction in the patient record. 

Here’s how CipherHealth helps.

Maximizing reimbursement with scalable outreach

As health systems continue to face economic pressures, providers are in need of ways to retain revenue while still providing exceptional patient care — even after the patient has left the hospital setting. 

Providers participating in TCM programs can leverage CipherOutreach’s automated calls and scripts to scale their outreach efforts without the need for additional staff. While the interaction must be manually completed by the provider, CipherOutreach does the heavy lifting in getting patients to engage 24 hours post-discharge and connecting them directly to their provider with live transfer capabilities. From there, the care team will receive alerts if a patient requires additional follow up based on their responses, freeing up staff so they can dedicate time to the patients who need it most.

By leveraging automated outreach, health systems can increase patient participation and maximize their reimbursements — on average, providers can earn $205-$278 per discharge based on complexity of each case.

Supporting the TCM workflow

With CipherOutreach, health systems can stay connected to every TCM-eligible patient with targeted scripting and easy access to all patient responses.

Here’s how it works:

  1. Automated enrollment: A patient is discharged from the hospital and is automatically enrolled into a TCM outreach program via CipherHealth.
  2. Automated post-discharge call: The patient receives an automated call within 24 hours of their discharge.
  3. Live transfer to nurse: The patient picks up the call and answers all required questions. Once they’ve completed their responses, they’re placed on hold and transferred by CipherOutreach to a live nurse.
  4. Discharge review, medication check, and follow-up coordination: The call team nurse confirms the patient’s identity and uses CipherOutreach’s dashboard to structure and document the call, including a review of discharge instructions, medication reconciliation, and coordination of a follow-up appointment if needed. 
  5. Call documentation: The call team nurse notes the interaction details in the EMR as a telephone encounter.

Providing seamless care to patients

Using CipherOutreach to support TCM programs brings various advantages to patients and health systems alike. Here are four benefits of automated outreach for TCM:

  1. Meet TCM requirements without burdening staff: Save staff time by automating scheduled calls to eligible patients with customized, best-practice scripts.
  2. Ensure timely access to data: Provide staff with access to data and analytics during their interactions, enabling them to make informed decisions for patients.
  3. Overcome language barriers: Utilize multiple language barriers to meet the needs of your patient population.
  4. Seamless sync data with your EHR: Capture each outreach attempt and patient responses with a bi-directional HL7 feed to the EHR.

Incorporating technology-driven solutions like CipherOutreach into TCM programs is a transformative step. It empowers healthcare systems to engage more effectively with patients post-discharge, providing tailored support, timely interventions, and a reduction in hospital readmissions. In doing so, they ensure patients’ needs are being met, improving satisfaction and lowering healthcare costs — all while generating significant revenue through reimbursements.


Meaningfully connect with your patients to deliver more personalized, intelligent and timely care at scale