Situation

Transitional Care Management (TCM) is critical to ensuring discharged patients receive the follow-up they need. For care organizations, this pathway is vital to reducing preventable readmissions and improving patient outcomes. However, the process is often bogged down by manual workflows.

In many organizations, managing TCM involves reviewing Admission/Discharge/Transfer (ADT) messages, cross-referencing ICD-10 codes, and identifying patients who need follow-up—all done manually. Teams use spreadsheets, email chains, and human processes to prioritize and coordinate care. This approach is resource-intensive, error-prone, and creates a significant workload for caregivers.

Complication

Handling TCM manually puts enormous strain on clinical teams. Care coordinators must sift through hundreds of ADT messages daily, decipher incomplete data, and manually determine next steps for each patient. Missing or inaccurate information—like a phone number, discharge diagnosis, or primary care provider—can slow down the process further, requiring teams to track down missing data.

This workload not only stretches resources but also increases the risk of patients falling through the cracks. With no efficient way to prioritize who needs attention first, preventable readmissions become a costly and avoidable reality.

Resolution

Care teams use Awell to simplify Transitional Care Management (TCM) by automating workflows and turning data into actionable care processes. ADT messages are processed automatically, patients are identified using ICD-10 codes, and follow-ups are triggered via SMS, email, or AI agents—eliminating the need for spreadsheets or manual prioritization.

To address data gaps, care teams integrate steps to reconcile missing information, ensuring no patients are overlooked. Teams can continuously iterate by adjusting workflows, refining logic, and improving messaging based on real-world feedback.

By reducing manual tasks and enabling smarter prioritization, our customers ease caregiver strain, prevent patients from falling through the cracks, and deliver better outcomes with less effort.