Transitional Care Management
HIPAA-secure • EHR-ready • Built for clinics, ACOs, and post-acute teams
Discharge Isn't the Finish Line
- One in five Medicare patients lands back in the hospital within 30 days.
- Missed follow-up calls put CMS reimbursement-and patient safety-at risk.
- Staff juggle phone tags, med reconciliation, and paper care plans.
Without the right system, gaps appear fast and readmissions follow.
Every Gap Costs More Than a Bed
Meet D2D: The TCM Platform
That Closes Every Loop
AI-Driven Task Engine
Prioritizes calls, med reviews, and care-plan steps so nothing slips.
Smart Patient Outreach
Text, email, or IVR nudges schedule follow-ups automatically.
Real-Time Risk Flags
Clinical rules surface patients trending toward readmission.
Seamless Billing
Auto-captures documentation for CMS 99495 & 99496.
EHR Integration
Syncs notes, meds, and visit outcomes back to your chart with one click.
Compliance Ready
HIPAA-secure workflows and audit trails out of the box.
Discharge Feed
ADT/EHR event triggers enrollment.
First 48 Hours
Platform schedules initial contact; AI suggests questions.
Day 7 Check-In
Medication reconciliation & symptom review.
Day 30 Wrap-Up
Completion report & billing file sent automatically.
Reimbursement at a Glance
D2D tracks every minute and auto-populates billing, so you never leave money behind.
$190 Avg.*
Moderate complexity | Face-to-face visit within 7 days
*National non-facility average. Actual figures vary by MAC & geography.
$250 Avg.*
High complexity | Face-to-face visit within 7 days
*National non-facility average. Actual figures vary by MAC & geography.
Proof in the Numbers
34%
Reduction in 30-day readmissions
92%
TCM calls completed on time
$2.1M
New annual TCM revenue (2023)
“D2D cut our follow-up workflow from 45 minutes to 12 and almost eliminated missed deadlines.” – Clinical Operations Director, Midwest ACO
Frequently Asked Questions
Patients discharged from inpatient, observation, or SNF settings who receive a face-to-face visit within 7 days (99495) or 7 days with high complexity (99496) plus two additional non-face-to-face touches.
Yes – roles, scripting, and documentation templates match CMS requirements for both, giving your team flexibility without extra paperwork.
Most organizations go live in 30 days with EHR integration and staff training included.
Ready to Close the Post-
Discharge Gap?
Schedule a 20-minute demo to see how D2D drives safer transitions and full TCM reimbursement.