WellCare TCCM Services

Transitional Chronic Care Management

Annual Wellness Visits (AWV)

Integrated Behavioral Health (BHI)

Transitional Chronic Care Management


Transitional care is the bridge between hospital and home. We facilitate communication with all healthcare providers and caregivers involved to ensure clear and precise discharge instructions, including a thorough review of medications. We schedule follow up appointments with your physician and provide a house call with a Nurse Practitioner and access to medical providers by phone 24 hours a day. 

  • Personalized assistance from dedicated health care professionals ( Nurses and social workers)
  • Customized disease specific branch logic care plans
  • Monthly  patient calls
  • Assistance with setting and achieving health care goals
  • Medication review
  • Continued education on the patient’s chronic conditions
  • Assistance connecting with community resources
  • Direct dial care team number for easy access
  • Direct documentation into your EHR
  • Participation in the care team and practice meetings

Annual Wellness Visits ( AWV) 


Annual Wellness Visit helps the Medicare patients to create a plan which may help them to prevent illness based on the current health condition and other risk factors. This is a yearly appointment with the primary care provider to update or create a personalized prevention plan for the Medicare patients.

Annual Wellness Visit: Eligibility

You can be covered for the Annual Wellness Visit if you have Medicare part B for over 12 months. The eligibility criteria also requires that you should have not received an Annual Wellness Visit in the past 12 months since it is a yearly event.

The Welcome to Medicare Preventive Visit and Annual Wellness Visit cannot happen in the same year.

Integrated Behavioral Health ( BHI) 


Behavioral health encompasses behavioral factors in chronic illness care, care of physical symptoms associated with stress rather then disease, and health behaviors, as well as mental health and substance abuse conditions and diagnosis.

Provides patients with psychiatric or behavioral health condition(s) the following services:

  • Behavioral Health Care Assessment
  • Behavioral Health Care Planning
  • Provision of Interventions

Behavioral Health Integration 

  • Customized diagnosis specific care planning support
  • Monthly behavioral health calls
  • Medication review 
  • Coordination of care between office visits
  • Assistance connecting with community resources
  • Direct dial care team numbers for easy access
  • On-site behavioral health care management
  • Case reviews from a psychiatric consultant