Document Care Transitions Without Coordination Chaos
Starting January 2026, 741 hospitals face 30-day financial accountability for readmissions. OrbDoc's AI scribe helps you complete 5-minute discharge summaries, capture SDOH barriers, and optimize TCM billing. Achieve 30% readmission reduction and leave work on time.
$15K-$45K TCM billing opportunity • 30% readmission reduction • 5-minute discharge summaries
5 min
Discharge summaries vs 45-60 min
30%
Readmission reduction achievable
$15K-$45K
TCM billing opportunity annually
60 sec
Audit response vs 15-30 hours
TEAM Model Compliance Solutions
30-Day Financial Accountability
Comprehensive discharge documentation with SDOH capture. Readmission reduction saves $294K-$427K annually.
5-Minute Discharge Summaries
Automatically synthesize 3-5 day hospital stays into discharge summaries. Save 40-55 minutes per discharge vs traditional 45-60 minute process.
SDOH Documentation & Transfer
Capture and communicate social barriers affecting readmissions. Document transportation, housing, medication affordability barriers.
Evidence-Linked Audit Defense
7-year audio retention with claim-level timestamps. 60-second audit response vs 15-30 hours of manual chart review.
TEAM Model Financial Impact by Procedure
Under TEAM, hospitals are financially responsible for readmissions within 30 days of discharge. Here's the potential exposure and savings with 30% readmission reduction:
| Procedure Type | Baseline Readmit | Annual Volume | Current Risk | Potential Savings |
|---|---|---|---|---|
| Spinal Fusion | 5-8% | 100 cases | $75K-$120K annually | $52K-$84K saved |
| Lower Extremity Joint Replacement | 4-6% | 200 cases | $96K-$144K annually | $67K-$101K saved |
| Coronary Artery Bypass Graft (CABG) | 12-16% | 50 cases | $168K-$224K annually | $118K-$157K saved |
| Surgical Hip/Femur Fracture | 8-12% | 75 cases | $81K-$122K annually | $57K-$85K saved |
Total Annual Exposure: $420K-$610K
Potential Savings with 30% Reduction: $294K-$427K
Based on typical 300-bed hospital procedure volumes
SDOH Factors Driving 50% of Readmissions
Social Determinants of Health are responsible for half of all readmissions, yet most hospitals don't systematically capture or address them. TEAM Model makes SDOH intervention financially critical.
Transportation Access
Impact: Patients miss 50% of follow-up appointments without reliable transportation
Documentation: Document transportation barriers, arrange medical transportation, confirm follow-up access
Medication Affordability
Impact: 30% of patients don't fill prescriptions due to cost, leading to complications
Documentation: Screen for cost concerns, prescribe generics, connect to patient assistance programs
Housing Stability
Impact: Homeless or unstably housed patients have 3-5x readmission rates
Documentation: Document housing status, arrange post-discharge support, coordinate with social services
Food Security
Impact: Food insecurity correlates with diabetes, hypertension, and medication non-adherence
Documentation: Screen for food access, provide nutrition counseling, connect to food assistance
Health Literacy
Impact: Low health literacy leads to medication errors and missed warning signs
Documentation: Assess understanding, provide 8th-grade reading materials, use teach-back method
Caregiver Support
Impact: Patients without caregivers have higher complication rates post-discharge
Documentation: Identify caregiver, document support system, arrange home health if needed
Comprehensive Discharge Process
Pre-Discharge Planning
Activities:
- • Identify discharge barriers early
- • Begin SDOH screening
- • Coordinate post-acute needs
- • Schedule follow-up appointments
Documentation:
Daily progress notes capture emerging barriers and coordination efforts
Discharge Day
Activities:
- • Final medication reconciliation
- • Patient education delivery
- • Caregiver education
- • Discharge summary generation
Documentation:
Comprehensive discharge summary with SDOH, medications, follow-up plan
Post-Discharge Follow-Up
Activities:
- • 48-hour phone call
- • Follow-up appointment completion
- • Medication adherence check
- • Red flag symptom monitoring
Documentation:
Transitional care management notes documenting 30-day episode
Traditional Discharge vs. TEAM-Ready Approach
Traditional Approach
Generic discharge instructions printed from EHR template
Common Issues:
10-15% readmission rate
Typical readmission rate
TEAM-Ready with OrbDoc
Comprehensive discharge process with SDOH intervention
Complete Solution:
7-10.5% readmission rate (30% reduction)
30% reduction achievable
6 Care Transition Scenarios Supported
OrbDoc's AI scribe optimizes documentation across the entire care transition workflow, from discharge planning to TCM billing.
TCM Billing Optimization
7-day and 14-day post-discharge visits for transitional care management
Outcome: $15K-$45K annual opportunity (50-100 transitions × $167-$239 per visit)
Discharge Planning Documentation
Multi-day hospital stay consolidation into comprehensive discharge summary
Outcome: 5-minute discharge summaries vs 45-60 minutes manual process. Same-day completion.
SNF Coordination
Skilled nursing facility care transition with medication reconciliation
Outcome: Clear SDOH barriers documented for SNF staff, reducing readmission risk by 30%
Home Health Transitions
Hospital-to-home transitions with home health agency coordination
Outcome: Transportation, caregiver support, medication affordability documented for home health
Medication Reconciliation
Post-discharge medication list alignment with what patient actually takes
Outcome: 30% of readmissions prevented by addressing medication affordability and adherence
Follow-Up Visit Documentation
48-hour phone call, 7-day visit, 14-day visit for TEAM compliance
Outcome: Structured TCM notes documenting 30-day care episode for billing and audit defense
Built for Small Hospitalist Groups That Enterprise Care Coordination Platforms Overlook
Small hospitalist groups managing transitions (2-8 providers), ACOs with readmission penalties, community hospitals under 100 beds. Enterprise care coordination platforms target large health systems with massive IT departments. OrbDoc focuses on your segment.
TEAM Model Compliance Features
5-minute discharge summaries from multi-day notes (vs 45-60 minutes manual)
SDOH structured data capture (housing, transportation, food security)
Medication reconciliation documentation with patient's actual medications
Follow-up appointment coordination tracking and verification
Post-acute care provider communication (SNF, home health, PCP)
30-day care episode tracking for TEAM compliance
Readmission risk assessment documentation with SDOH integration
Care transition checklist completion before discharge
Patient education material generation (8th grade reading level)
Evidence-linking with audio timestamps for TEAM audits
TCM billing optimization: $15K-$45K annual opportunity
CMS TEAM model compliance reporting and quality measures
Success Patterns from Care Transition Teams
Small Hospitalist Groups
Hospitalist groups with 2-8 providers managing TEAM Model transitions report:
- • 5-minute discharge summaries vs 45-60 minutes manual
- • $15K-$45K TCM billing opportunity captured annually
- • Leave hospital by 5pm consistently, no evening discharge documentation
Primary Care Receiving TCM Patients
Primary care practices receiving post-discharge patients report:
- • 7-day and 14-day TCM visits documented in 5 minutes per patient
- • SDOH barriers from hospital clearly documented for follow-up
- • $20K-$35K annual TCM revenue for 50-75 transitions
Community Hospitals Managing Readmissions
Community hospitals under 100 beds with TEAM Model penalties report:
- • 30% readmission reduction saves $50K-$200K in avoided penalties
- • 60-second audit response vs 15-30 hours of manual chart review
- • Same-day discharge summary completion, no backlog
Revenue and Cost Avoidance Opportunity
TCM Billing Optimization
50-100 transitions × $167-$239 per visit (7-day/14-day)
Readmission Penalty Avoidance
30% reduction in readmissions for TEAM Model procedures
Time Saved Per Discharge
5-minute summaries vs 45-60 minutes manual process
Total Annual Opportunity: $65K-$245K
For small hospitalist group managing 50-100 care transitions annually
Hospitalist groups managing TEAM transitions report completing discharge summaries in 5 minutes vs 45-60 minutes. Joint replacement readmissions reduced from 6% to 4.2% representing $200K+ in avoided penalties. Evidence-linking provides 60-second audit response.
Hospitalist Group
5-provider group managing 80 transitions annually
Related Care Transition Solutions
Leave Work on Time, Reduce Readmissions, Optimize TCM Billing
Implementation takes 3-6 months. Start now to be ready for TEAM Model compliance. Stop staying until 7pm for discharge documentation. Achieve 5-minute summaries and leave by 5pm.
Opportunity: $65K-$245K in TCM revenue and avoided readmission penalties
741 hospitals must comply • Mandatory start: January 1, 2026 • Start now to be ready