Transitional care management that closes the loop after discharge

Primary Care Streams turns every hospital discharge into a tracked, deadline-aware workflow — so your practice captures the follow-up, meets TCM requirements, and bills with confidence.

How it works

From discharge to billing-ready, without the spreadsheet

01

Discharge lands

An ADT or discharge record flows in and opens a transitional care journey automatically — no manual intake.

02

Interactive contact

The two-business-day outreach clock starts. Log the contact and the countdown clears itself.

03

Med rec & follow-up

Medication reconciliation and the face-to-face visit window are tracked against TCM deadlines.

04

Billing-ready

Once every requirement is met, the encounter is flagged eligible with the right CPT level.

Compliance

Every requirement, tracked and auditable

TCM has strict timing and documentation rules. Primary Care Streams encodes them into the workflow so your team always knows what is due, what is overdue, and what is ready to bill.

Deadline-aware timelines

Every discharge carries a live countdown for interactive contact and the follow-up visit, so nothing slips past the TCM window.

Clinical checklist

Records collection, medication reconciliation, and visit completion are captured as structured, auditable steps.

HIPAA-covered from day one

Business Associate terms are accepted before any PHI is touched, and the workspace is scoped to your practice.

Capture the revenue you have already earned

When a discharge meets every TCM requirement, Primary Care Streams marks it billing-ready with the correct CPT level — turning careful follow-up into reimbursed care.

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