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
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.
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.
How D2D TCM Works
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