Every patient deserves a safety net.
Now, they all have one.
3,500
fewer predicted readmissions over 16 months.
26%
improvement in TCM visit capture.
ZERO
TCM charge denial.
How a Leading Health System Boosted TCM Billing by 26% with CipherOutreach
We’re now able to support patients we never had the resources to reach before. CipherOutreach gave us a way to scale care in a way that’s both personal and efficient. And our nurses are resolving issues faster than ever — often before patients even think to call us.
Every patient deserves a safety net.
Now, they all have one.
3,500
fewer predicted readmissions over 16 months.
26%
improvement in TCM visit capture.
ZERO
TCM charge denial.
Background
One of the nation’s largest nonprofit health systems, with more than 60 hospitals spanning the Midwest and Southeast, has steadily expanded its partnership with CipherHealth. Improving TCM billing with CipherOutreach has become an essential part of this partnership. The relationship began several years ago when the system implemented leader rounding in Illinois. As the organization grew, so did its need for consistent, enterprise-wide ways to connect with patients across care settings. What started as a focus on rounding has evolved into a broader strategy powered by CipherHealth’s patient-facing operating system, supporting the system’s enterprise goals for quality, safety, and experience.
The Challenge
This health system’s care teams were already conducting nurse-led follow-up calls for high-risk patients. But those efforts covered only a fraction of discharged patients. Leaders realized nearly half of readmissions were coming from moderate-risk, low-risk, and observation patients.
The issue wasn’t care quality, it was capacity. With limited staff, they couldn’t possibly reach every patient post-discharge. To create a true system-wide safety net — one that could reduce readmissions, improve TCM capture, cut down on avoidable ED visits, and remain budget neutral — they needed a scalable, technology-enabled approach.
Solution: CipherOutreach for TCM
The system expanded its transitions-of-care program with CipherOutreach, creating a centralized model that touches every patient after discharge.
How it works:
- Every patient receives a series of five follow-up calls or texts within 30 days, starting within 48 hours post-discharge.
- A centralized care transitions team monitors responses and alerts seven days a week from 8:00 a.m. to 8:00 p.m., fulfilling CMS requirements for interactive contact.
- Patient-reported issues trigger real-time alerts for the care team to respond immediately.
- The program is fully integrated with Epic via flowsheets, enabling compliant TCM billing and streamlined
clinical workflows.
Results
One Day at a Glance: On average, for moderate-risk, low-risk, and observation patients, the program delivers:
–
Big Picture Impact: Since launch, CipherOutreach has helped the health system:
–
CipherHealth Deep Dive: In a joint analysis of the first 100,000 patients:
–
Looking Ahead
The success of this TCM initiative is fueling enterprise-wide expansion, with regions in the Southeast now adopting the same model. For this large, multistate health system, CipherOutreach has proven that equitable, timely follow-up is possible at scale.
When patients leave the hospital, they shouldn’t feel like they’re on their own. With CipherOutreach, they no longer are.
