eClinicalWorks Blog Details

  • 13 September 2022
  • Blog

Keeping an Eye on Patients in Transition


Transition Care Management helps reduce hospital readmissions

No one likes going to the hospital; however, getting the care we need sometimes requires making the trip. What shouldn’t be necessary is being readmitted to the hospital because a provider lost track of where a patient was, didn’t check to see what medications they were on, or was too slow to provide necessary follow-up care.

eClinicalWorks® developed our Transition Care Management (TCM) module to help give providers a set of tools to ensure the continuity and quality of care for patients moving between acute and ambulatory settings, including hospitals, rehabilitation facilities, their primary care doctor, and their homes.

Such times of transition can be as challenging for providers as for the patients themselves.

Transitions can mean vulnerability, but there are solutions

An article in The Gerontologist® noted that care transitions, particularly among older adults, “are a time when the risk for medical errors and adverse events is high. These problems are costly by themselves, but poorly managed transitions generate additional costs in terms of suffering, repeated and unnecessary tests and recidivism.”

The article cited studies showing the value of:

  • Making full assessments for patients being discharged from a hospital
  • Giving referrals for follow-up care with primary care physicians or specialists
  • Ensuring that social supports are in place for patients returning home
  • Placing follow-up phone calls to monitor patients’ post-hospital progress

How the TCM module can help

Our ready-to-use module can help improve a practice’s efficiency and productivity by reducing the risks of rehospitalization, promoting better patient outcomes, and helping control the costs of care.

The module includes:

  • An integrated dashboard for management of patients transitioning among care settings
  • Analysis and tracking tools that help ensure care is delivered on time for each patient
  • Integration with eClinicalMessenger® to facilitate patient outreach

Real-world success using TCM

In this edition of the eCW Podcast, Matt Cady from Florida’s Adult Medicine of Lake County discusses how his practice has made effective use of the TCM module.

Cady said he knows of many practices that use paper records and notes to manage patients who are in transition. While that method is possible, he said it is much easier and safer to use a solution like the TCM module, which not only provides the practice with a tool for tracking patients but helps them significantly reduce hospital readmissions.

“Upon transition out of the hospital back into the primary setting, the patient is incredibly vulnerable,” Cady said. “The family can be involved, there may be discharge orders, referrals, and a lot of things that are needed. So, the sooner we can get ahold of that patient, reconcile their medications, and make sure they’re on a firm footing getting back home — that reduces their chances of being readmitted to the hospital.”

For more information or to schedule a demo, contact

Next month, our Population Health blog series looks at the eClinicalWorks Remote Patient Monitoring (RPM) module. RPM gathers physiological data from patients’ wearable health devices to gain insights, interpret health trends, and help providers manage chronic conditions, promote better medical outcomes, and lower costs.

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