Transitional Care Management • AI-Powered

Transitional CareManagement Made Simple

Reduce 30-day readmissions, capture every TCM dollar, and keep patients on track with one AI-powered workflow.

HIPAA-secure • EHR-ready • Built for clinics, ACOs, and post-acute teams

Discharge Isn't the Finish Line

Patient consultation illustration highlighting post-discharge risks
  • 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

A single unplanned readmission can exceed $15,000 and trigger CMS penalties. Meanwhile, each missed TCM service leaves $180–$250 unreimbursed. The cycle strains budgets, frustrates care teams, and shakes patient trust.

TCM cost illustration: hospital bed, calculator, and dollar sign

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.

Process Overview

How D2D TCM Works

1

Discharge Feed

ADT/EHR event triggers enrollment.

2

First 48 Hours

Platform schedules initial contact; AI suggests questions.

3

Day 7 Check-In

Medication reconciliation & symptom review.

4

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.

99495

$190 Avg.*

Moderate complexity | Face-to-face visit within 7 days

*National non-facility average. Actual figures vary by MAC & geography.

99496

$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

Ready to Close the Post-Discharge Gap?

Schedule a 20-minute demo to see how D2D drives safer transitions and full TCM reimbursement.