Solutions
Solutions
Transitional Care Management
About one in five Medicare patients returns to hospital within a month of discharge — a gap that costs the system more than $25 billion a year and costs patients their independence.
Med-IT's transitional care workflow reaches patients within the critical window, reconciles medications, arranges follow-up and keeps a coach involved until the patient is stable at home.
Why it works
Outreach begins within two business days, while the discharge plan is still fresh.
Pre- and post-hospital medication lists are compared, with discrepancies flagged to the practice.
Appointments are scheduled and confirmed, with reminders through phone and app.
Coaches check in through the highest-risk period and escalate red flags immediately.
Every engagement is scoped to your practice, but the core program looks like this:
Daily discharge census review
Two-business-day patient contact
Medication reconciliation
Follow-up appointment scheduling
Symptom and vitals check-ins
Red-flag escalation protocols
Care plan handoff to primary care
Readmission tracking
Sub-services
Each part can run inside the program or be added on its own — the same team and the same record either way.
Daily census review flags patients entering the 30-day window.
Pre- and post-hospital lists compared, discrepancies flagged to the practice.
Appointments booked and confirmed, with reminders by phone and app.
How it works
The same five-stage model runs behind every program — visible in the platform and documented for billing.
Discharged patients are flagged from your census or hospital notifications.
A coach reaches the patient quickly and confirms the follow-up plan.
Medications, symptoms and appointments are reviewed and corrected as needed.
A summary returns to the practice and the patient stays supported for 30 days.
Billing
Med-IT documents the encounters and time requirements these codes depend on. Eligibility always depends on the patient and payer.
Billing rules and coverage change. Confirm current requirements with CMS and your payer before submitting claims.
Patient experience
Programs are designed for long-term participation — not a one-time device drop.
A call shortly after they get home
Help understanding new medications
A confirmed follow-up appointment
Someone to call if something feels wrong
Keep exploring
Get started
We will walk through your panel, the workflow and the billing requirements — then show the platform with your scenario.