Primary care providers (PCPs) participating in accountable care organizations (ACOs) are responsible for much more than the services they provide during any specific encounter.

As an important component of Aledade's Core 4 services, transitional care management (TCM) is designed to bridge the gap and ensure that primary care providers follow up with their patients in a structured, reimbursable manner after discharge from a hospital, skilled nursing facility, inpatient rehab facility, or certain other settings.