Story by Connor Danielowski / May 19, 2025
At Chronic Care Staffing, we pride ourselves on being more than just a staffing partner—we’re a true extension of our clients’ care teams. And nowhere is that more evident than in our recent Transitional Care Management (TCM) work with a Community Health Center (CHC), where our team is consistently achieving over 90% patient engagement and scheduling success rates.
Many CHCs struggle to consistently connect with patients during the critical post-discharge window. Between staff limitations, technology hurdles, and patient availability, it’s easy for these follow-up efforts to fall through the cracks—often leaving care gaps and lost revenue behind.
But at this CHC, our team has stepped in to help close that gap. Currently, we’re connecting with about 9 TCM patients per day, and our performance consistently exceeds the internal team’s reach rate. In fact, the clinic’s leadership asked for our “secret sauce”—curious how we were managing to engage patients so effectively where their internal staff had struggled.
The key to our success lies in our process. Our coordinators bring:
Rather than settling for one attempt, we follow up with intention, knowing that every successfully scheduled TCM encounter is not just billable, but potentially life-changing for the patient. We’ve also built an internal tracking system that ensures no encounter is missed, even when it falls outside of Atlas reporting or exceeds the monthly 60-minute threshold.
To ensure nothing slips through the cracks, our team maintains a dedicated spreadsheet that tracks every HRA and TCM encounter—including those that can’t be logged in real-time due to EHR billing limitations. In one month alone, we tracked 30 additional TCM encounters outside of Atlas—calls that might otherwise have gone unrecorded and uncredited.
This level of oversight gives our partners confidence that their patients are cared for—and their reimbursements are fully captured.
With performance metrics this strong, we’re excited about the opportunity to expand our role and take on even more of the TCM volume for this CHC. We know the need is there—and we’ve proven that the capability is, too.
Whether it’s Transitional Care Management, Health Risk Assessments, or full-service CCM, Chronic Care Staffing brings the tools, the team, and the attention to detail needed to make every patient connection count.
Let’s talk. We’ll show you how we can deliver consistent, compliant, and compassionate follow-up for your post-discharge patients—without adding to your team’s workload.
Schedule a free consultation today.
Serving clinics, CHCs, and healthcare systems nationwide.
Chronic Care Staffing – Proven Outcomes. Patient-Centered Coordination.
