Transitional Care Management (TCM) Software
Discharges and ER visits arrive as TCM episodes with the 2-, 7-, and 14-day windows already running, ranked by readmission risk. Care teams complete the interactive contact, book the follow-up visit, and capture what is needed to bill — from one screen.
Transitional Care Management in DAX Vantage
TCM episodes with compliance windows
Discharges and ER visits arrive as episodes with 2-, 7-, and 14-day windows, so the team sees exactly how much time is left on every patient.
Interactive-contact checklist
The contact requirements are tracked step by step against each episode, alongside the CPT and medical decision making (MDM) billing details.
Readmission risk ranking
A built-in model using LACE, prior admissions, age, ED use, and length of stay ranks discharges by risk, so the highest-risk patients are called first.
TCM follow-up queue
Open post-discharge windows in one queue, with a one-click video visit for the face-to-face follow-up.
AI post-discharge check-in calls
Optional outbound AI care calls check in with patients after discharge, record their answers, book the follow-up, and hand anything clinical or urgent to staff.
Common questions
How does DAX Vantage support TCM billing?
Each discharge or ER visit becomes a TCM episode with 2-, 7-, and 14-day windows, an interactive-contact checklist, and the CPT and MDM billing details, so the documentation needed for the claim is captured as the work is done.
How are post-discharge patients prioritized?
A built-in readmission risk model — LACE, prior admissions, age, ED use, and length of stay — ranks every discharge, and the TCM follow-up queue shows the open windows with a one-click video visit.
Works with the rest of DAX Vantage
One patient view and one prioritized list of work for every care manager.
Quality & HCC Risk AdjustmentCare gaps, quality measures, and AI-assisted HCC coding from one shared definition.
Patient Engagement & AI OutreachWorkflow-driven outreach over text, phone, and email — with optional AI assistants and compliance built in.
Scheduling & TelehealthVisits booked against real availability — from the app, the patient portal, or the AI assistants.
Population Health AnalyticsCost, utilization, quality, and team output from the same data the care teams work from.
See transitional care management in DAX Vantage.
Tell us which contracts you are accountable for and where your care teams lose time today. We will show you what DAX Vantage looks like for that work.