Transitional Care Management Solutions

Support Your Patients during Care Transitions
to Reduce Readmissions

As a direct result of an aging population, rising costs, and declining outcomes, the healthcare industry is at a critical crossroad. More and more patients are falling into moderate to high-risk categories, making them significantly more vulnerable to readmission after they leave the hospital. In fact, about 20% of all Medicare beneficiaries discharged from hospitals return to the hospital within 30 days which costs Medicare around $26 billion per year.

In 2013, CMS started reimbursing for Transitional Care Management (TCM) in an effort to prevent these readmissions and to allow providers to receive reimbursement for their efforts. However, following up on patients once they leave the practice or organization requires a lot of logistical arrangements, education of the patient and their family as well as coordination among the health professionals involved in the transition.

Centro Healthcare helps your organization achieve clinical success by tracking and communicating patient care, protocols and progress across the healthcare system. Our patient engagement solutions are designed to substantially enhance your existing care transition services with industry-leading efficiency and effectiveness.

Our Transitional Care Management Services

Centro Healthcare’s multipronged approach efficiently supports your practice in delivering Transitional Care Management services to reduce readmissions and develop a new revenue stream while minimizing any disruptions to your practice and existing workflow.

EHR Integration & Customization

Our seamless EHR integration and customization enables you to access real-time data and efficiently monitor your post-discharge patients (inpatient, outpatient, or ER)

Eligible Patients Identification

We identify and capture eligible Transitional Care Management beneficiaries from your practice workflow based on follow-up care model to make the contacts that are required within 2 days of discharge to schedule face-to-face visits (within 7 or 14 days), and perform the non-face-to-face follow up.

Patient Outreach and Engagement

Centro Healthcare guarantees comprehensive post-discharge care. Our CMAs connect with your patients to assess their health status, escalate clinical resources, review care instructions, schedule necessary follow-up care, and gather patient experience feedback.

Personalized Post-Discharge Follow up

We offer a patient-centric, comprehensive solution that provides individualized plans of care as well as continuity across the continuum of post-acute care and manages patient cases from day one of the inpatients stay to 30, 60, or 90 days after discharge from the acute setting.

Remote Patient Monitoring

Inadequate communication and patient non-compliance account for many hospital readmissions. Centro Healthcare helps in maintaining the continuity of care through remote vitals monitoring and integration with trackers and wearable devices to help patients continue their path to recovery.

Streamline Patient Enrollment

We provide full enrollment support through identifying and enrolling eligible CCM beneficiaries from your EHR to maximize your revenue and make the most out of the Care Management and Transitional Care Coordination

24/7 Care Support

Our certified medical professionals are available 24/7 for urgent care support or on-call services, with access to patients’ records.

EHR Documentation

We track all encounters, episodes, services and incorporate all patients’ post-discharge care summary into the EHR to generate actionable analytics and reports for transitional care improvement and provide you with comprehensive documentation for your continued access and review.

Monthly Auditable Reports

We create standardized patient reports to provide you with an auditable report at the end of each month which enables you to stay in compliance with CMS’s requirements.

Benefits of Outsourcing Transitional Care Managment (TCM)

Centro Healthcare helps you fully utilize the benefits of Transitional Care Management as a tool to:


Transitional Care Management improves health outcomes by identifying patients’ modifiable health risks and providing follow-up behavior change intervention which ultimately enhances the continuity of care from hospital to home and helps in keeping patients out of the hospital and long-term care facilities.


Improve Patient Engagement

Transitional Care Management encourages Medicare patients to continue to routinely see their physician for follow-up care and treatment which leads to enhanced patient outcomes and higher patient satisfaction

Generate Additional Revenue

Generate additional revenue for your practice. As the CMS national payment amount for CPT code 99495 of moderate complexity is $163.99, and for CPT code 99496 high complexity is $231.36. The additional reimbursement compensates for all non-face-to-face activities.

Reduce Readmissions

Reduce readmission rates, the need for overutilization such as ED visits for primary care services and their related costs.


Stay in compliance with CMS’ requirements and guidelines through our comprehensive auditable reports

Centro’s Workflow for Transitional Care Management

Centro Healthcare simplifies your TCM workflow and allows you to effectively offer Transitional Care to your patients without any changes in your current workflow nor additional administrative burdens to your practice.


EHR integration
Extract Patient’s data


Identify all TCM eligible Patients


Outreach to Patients
Educate them on the benefits of TCM


Gather discharge clinical data
Personalized post-discharge follow-up
Schedule in-office appointments


Document data on EHR
Create auditable report


Provide billing documents
99495 TCM Moderate Complexity
99496 TCM High Complexity