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Transitional Care Management Services

Our TCM program is a complete, turn-key service that focuses on CMS HRRP conditions and procedures. We work closely with our hospital partners, beginning before discharge, to successfully transition patients back into their home environment.

Getting Started with TCM

AlzBetter's TCM program eliminates costly and time-consuming investments in software and clinical staff. We offload the burden of patient contact and clinical monitoring, so you can focus exclusively on medical decision making for cases that warrant further care. Our customizable process typically includes:

  • Early collaboration with hospital case managers and staff
  • Completion of post-discharge human outreach to patients within 24 hours, and scheduling of physician appointments within 7 days
  • 24-7-365 patient access to AlzBetter’s clinical staff
  • Medication review and reconciliation, with pharmacy and physician follow up
  • AlzBetter social workers can address transportation, financial, or psychosocial issues

Did you know?

In partnership with a leading heart and lung center, our TCM program cut 30-day readmission rates in half in the first year.
In the next three years we cut them in half again.

Level Up Your Transitional Care

AlzBetter helps you manage and coordinate all aspects of care among various settings, including inpatient, outpatient, primary and specialty care. Our focus on coordination, data collection, and patient-centric engagement can help you:

  • Reduce costly readmissions
  • Elminate Medicare HRRP penalties
  • Improve patient outcomes and satisfaction
Contact us

We can help you improve patient care, satisfaction, and profitability.

AlzBetter Advantages

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We help you build relationships with your patients that recognizes their humanity as well as the needs of their disease.

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Our training has been reviewed by a team of leading physicians, as well as the Alzheimer's Association®. Every topic meets evidence-based guidelines for dementia care.

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Our care processes, software algorithms, and analytics have been developed to optimize care while improving profitability

Learn more about how AlzBetter can help you
improve care, patient satisfaction, and profitability

Contact us