BloomTransitions
Special Post-Discharge Support for TCM Patients
BloomTransitions helps patients safely transition from hospital or facility discharge back into the home setting with structured RN-led follow-up and provider escalation.
- Contact attempt and post-discharge outreach support
- Medication reconciliation support and medication barrier review
- Follow-up appointment coordination
- DME, home health, transportation, and caregiver barrier identification
- Red-flag symptom education and escalation
- Readmission-risk tracking during the transition window
CPT Codes + RN Responsibilities
- 99495
- 99496
- Recent discharge from hospital, SNF, rehabilitation facility, psychiatric hospital, or similar eligible setting
- High-risk chronic disease, medication complexity, caregiver involvement, or elevated readmission risk
- Review discharge instructions
- Identify unresolved symptoms or worsening condition
- Support medication reconciliation workflow
- Confirm follow-up appointments
- Escalate urgent concerns to provider team
Care Pathways Across Every Specialty
BloomCardio™
Cardiovascular
BloomNeuro™
Neurology
BloomOnco™
Oncology
BloomRenal™
Kidney Disease
BloomGI™
Gastrointestinal
BloomBreathe™
Respiratory
BloomBlood™
Hematology
BloomMeds™
BloomNutrition™
BloomFunction™
BloomWounds™
BloomTransitions™
BloomMetabolic™
Bloom360™
BloomCare™Caregiver Support Layer
BloomCare Caregiver Connect
A caregiver-centered support program designed to help families stay informed, engaged, and supported throughout the patient’s care journey.
Supporting the People Who Support the Patient
Caregiver Connect helps reduce confusion, improve care follow-through, strengthen communication, and identify caregiver strain before it becomes a crisis.
- Caregiver check-ins
- Education and guidance
- Care team communication support
- Burnout and strain awareness
- Escalation when caregiver concerns affect patient safety or care plan adherence
Caregiver-Related Support Areas
- Caregiver communication may support CCM time when tied to the patient’s eligible care plan and requirements are met
- Caregiver communication may support TCM time during the transition window when clinically relevant and requirements are met
- Caregiver support may support BHI coordination when behavioral health needs and program requirements are met
- Confirm appropriate consent and authorization
- Assess caregiver barriers and strain
- Reinforce care-plan instructions
- Route caregiver concerns to RN/provider team
- Document caregiver communication and escalation
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Add-On Supports
Whole-Person Support Around BloomCore
BloomCare’s add-ons help address the barriers that often prevent patients from staying engaged and improving between visits.
Behavioral Health Support
Emotional wellness check-ins, screening workflow support, care coordination, and escalation routing.
- 99484
- 99492, 99493, 99494
- G2214 when applicable
- Depression, anxiety, adjustment disorder, chronic disease-related behavioral barriers
- Screening support
- Longitudinal wellness check-ins
- Behavioral health referral coordination
- Urgent concern escalation
Nutrition Support
Chronic disease dietary support, dietitian coordination, food barrier identification, and nutrition goal tracking.
- 97802, 97803, 97804
- G0270, G0271 when applicable
- Diabetes, CKD, obesity, heart failure, hypertension, GI restrictions, malnutrition risk
- Identify nutrition barriers
- Coordinate dietitian workflows
- Support provider-approved dietary goals
- Escalate poor intake, dehydration, or weight-loss concerns
Movement + Wellness
Movement engagement, safe activity goals, fall-risk awareness, functional wellness, and therapy follow-through support.
- RTM support areas: 98975, 98977, 98980, 98981 when requirements are met
- Deconditioning, obesity, fall risk, chronic disease activity barriers, post-discharge weakness
- Assess movement barriers
- Support activity goals
- Track therapy follow-through
- Escalate falls, pain, or functional decline
Medication Support
Medication adherence, refill barrier identification, reconciliation support, side-effect triage, and provider/pharmacy routing.
- Medication-related work may support CCM, PCM, BHI, or TCM time when criteria are met
- Polypharmacy, long-term medication use, medication nonadherence, complex chronic disease medication needs
- Medication reconciliation support
- Refill barrier review
- Side-effect triage
- Provider/pharmacy routing