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PharmD Live Solution

Transitional Care Management (TCM)

Proactive care. Better outcomes. Lower costs.

Structured post-discharge contacts, med reconciliation, and appointment coordination to cut readmissions.

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The PharmD Live® Difference

Seamless Transitions from Hospital to Home

Patients are vulnerable to complications and readmission in the 30 days following hospital discharge. Transitional Care Management (TCM) supports them during this high‑risk period. PharmD Live®’s TCM program provides structured follow‑up and care coordination to ensure a safe return to the community.

Timely Contact
Face‑to‑Face Visits
Medication Reconciliation
Seamless Transitions from Hospital to Home
Core Capabilities

Key Components of Our Transitional Care Management Program

Explore the clinical, operational, and technology capabilities that work together to improve care delivery and performance.

Featured Capability

Timely Contact

Care managers reach out within two days of discharge.

Integrated Capability Network 7 connected capabilities
Face‑to‑Face Visits
Medication Reconciliation
Care Coordination
Patient & Caregiver Education
Resource Connections
Billing Support

Face‑to‑Face Visits

Patients receive an in‑person or telehealth visit within seven days (high complexity) or 14 days (moderate complexity).

Medication Reconciliation

Pharmacists review medications to prevent interactions or duplications

Care Coordination

Collaborate with specialists, community services and caregivers.

Patient & Caregiver Education

Provide self‑management support and address signs of worsening conditions.

Resource Connections

Link patients to community resources and social services for additional support.

Billing Support

Document and bill TCM codes (99495 or 99496).

Benefits & Impact

Benefits & Impact of Transitional Care Management

Benefits & Impact of Transitional Care Management

Reduced Readmissions

Structured follow‑up and medication reconciliation lower the risk of rehospitalization

Improved Outcomes

TCM enhances adherence to care plans, reducing complications and supporting recovery.

Revenue Opportunities

TCM codes provide additional reimbursement for post‑discharge management, complementing CCM and APCM programs

Continuity of Care

Patients experience a seamless transition from inpatient to outpatient care, improving satisfaction and quality metrics.

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Why PharmD Live®

Why PharmD Live®

Our TCM program leverages pharmacists, nurses and care coordinators to deliver comprehensive post‑discharge support. We integrate TCM with CCM and APCM modules for a unified approach. Our technology automates scheduling, documentation and billing, ensuring compliance and maximizing revenue. Patients receive the right support at the right time, reducing readmissions and sustaining value‑based performance.

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