transitional care management cms

Optimizing transitional care management.

In 2013, the Centers for Medicare & Medicaid Services (CMS) took a significant step to improve care transitions for patients leaving acute care settings. To improve transitional care management, CMS began paying for the services involved in coordinating post-acute care for patients. By focusing on transitional care management, CMS intended to make it easier for healthcare organization to implement more effective transitional care services.

The transition from acute to post-acute care and recovery is often patient challenging time for patients and providers alike. Coordination of care becomes more difficult as patients are referred to multiple care settings. Communication with patients after they’ve been discharged is more challenging, and ensuring that patients have received and are following their post-acute care instructions requires significant resources and time. When transitional care management (TCM) fails, patients may experience setbacks during their recovery or be readmitted to the hospital. As a result, patient satisfaction decreases and the cost of providing health care rises

Yet optimizing transitional care management for CMS reimbursement is not an easy feat. Few healthcare organizations are equipped to handle the coordination, communication, education and decision-making required to substantially improve transition management.

Fortunately, naviHealth provides TCM services that can help hospitals and health systems implement programs to improve transitional care management and meet CMS requirements – while also lowering costs and improving productivity.

An Experienced Partner

We’ve spent more than 18 years pioneering ways to improve every aspect of care transitions for health plans, providers and patients. From discharge planning efficiencies to managing risk for payors and providers, naviHealth is equipped to provide you with a tailored suite of capabilities.

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Improve transitional care management for CMS with naviHealth.

naviHealth is a pioneer in transition of care management, with nearly two decades of experience that uniquely positions us to manage and share risk with our partners. To assist healthcare organizations in streamlining transitional care management for CMS reimbursement, we provide clinical support services, scalable technologies, and advisory solutions and expertise. By partnering with naviHealth, health systems, health plans and post-acute providers can better manage transitional care to improve patient outcomes, reduce waste, lower cost and enhance productivity.

The patient journey may start at the hospital, but that’s only just the beginning.

naviHealth solutions for transitional care management

Our services in transitional care management include:

  • Scalable technologies that automate labor-intensive tasks, standardize the care transition process, streamline workflows and identify high-risk and high-needs patients.
  • Advisory solutions that deliver upfront assessments of clinical workflows to improve operational efficiencies, highlight key insights and benchmark provider performance.
  • Clinical support services that place expert staff in hospitals and post-acute facilities as part of a care team, guiding patients to appropriate post-acute settings and providing expertise to identify areas for clinical quality and process improvement.

Learn more about transitional care management and CMS requirements.


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