Coordinate hospital outreach efforts to succeed with TCM services

Why This Topic Matters

TCM programs depend on timely access to discharge information and coordinated follow-up after a hospital stay. For practices that want to build or strengthen these services, the article highlights the organizational and communication factors that can affect whether a program is practical and sustainable.

Article Sections

1. TCM program challenges and hospital information access

   Introduces the operational context for TCM services and discusses why access to discharge information can shape program performance. It also notes the broader value-based care environment affecting these efforts.

2. Steps you can take to succeed

   Provides a practical overview of workflow and outreach strategies practices may use when building a TCM program. The section frames several broad approaches for improving coordination and follow-up.

3. Assign a TCM point person

   Describes the role of a dedicated staff member in organizing care management tasks and supporting the program. It also touches on related staffing backgrounds and workflow responsibilities.

4. Contact hospitals – and don’t stop there

   Discusses outreach to hospitals and other care-transition sources as part of program development. The section covers relationship-building efforts and alternative channels for obtaining transition-related information.

5. Make a pitch to hospitals’ quality and pocketbooks

   Focuses on how practices may frame the value of post-discharge coordination when communicating with hospitals. It situates the discussion within quality measurement, readmissions, and payment environment concerns.

6. Reinforce optimal patterns with your patients

   Highlights patient-facing encouragement and follow-up behavior after discharge. The section emphasizes supporting proactive contact and appointment follow-through.