What are Transitional Care Management Services?
Transitional care management (TCM) services refer to the care and support provided to patients moving between different care settings, such as being discharged from a hospital to home or moving from a nursing home to home. The goal of transitional care is to ensure high-risk patients have the support and education needed to successfully transition and to prevent unnecessary readmissions or complications.
Elements of Transitional Care Management
Transitional Care Management Services typically involve several core components. Within two business days of discharge, the provider conducting TCM must communicate with the patient either face-to-face or via telehealth. During this initial communication, the provider assesses the patient's needs and medical issues to develop a core plan of care.
This plan of care aims to address any health concerns or care gaps that could complicate the transition. It may involve scheduling follow-up appointments, managing medications, arranging for physical therapy or home healthcare, or ensuring the patient understands potential warning signs to watch out for.
Ongoing Care and Coordination
Following the initial visit, the transitional care provider remains actively involved in coordinating and managing the patient's care. This includes arranging referrals to specialists, consulting with other physicians on the patient's treatment plan, and communicating regularly with the patient to monitor symptoms and address new issues.
The provider also coordinates with the facilities and health professionals involved in the patient's care both before and after discharge. Frequent communication ensures a smooth transition between settings and continuity of care. Transitional care management aims to bridge gaps that may otherwise lead to medical errors or preventable readmissions.
Addressing Social Determinants of Health
A comprehensive transitional care plan considers social factors like living situation, access to food/transportation, and caregiver support that could impact recovery and medication/treatment adherence. By addressing underlying social needs, transitional care aims to set patients up for success once medical oversight shifts from facilities to home-based care. This may involve referrals to community resources for food assistance, transportation vouchers, or home health aides.
Transitional Care Management and Reducing Readmissions
Research shows transitional care programs can significantly reduce preventable hospital readmissions, which are not only detrimental to patient health but also impose substantial costs on the healthcare system. Studies have found transitional care interventions lead to a 10-27% reduction in avoidable 30-day readmissions, especially among high-risk patients.
By addressing care gaps, medication reconciliation issues, and social barriers to care, transitional care management helps patients stay on track with recommended treatments and follow-up care instead of relapsing soon after discharge. Proper transitional support sets up an environment where patients are empowered and able to successfully transition between settings without complications.
Transitional Care Guidelines and Regulations
To support transitional care delivery, Medicare developed provisions allowing billable TCM services following hospitalization. TCM codes were expanded in 2015 to include discharge from an inpatient hospital stay, partial hospitalization, skilled nursing facility, or community mental health center.
Providers can bill for TCM by meeting with patients within two business days of discharge and providing at least 14 days of additional oversight like follow-up phone calls, medication adjustments and referrals for ongoing support. In 2021, transitional care codes generated over $900 million in Medicare reimbursements, reflecting growing recognition of the model's value. Many private insurers now also cover transitional care management services to improve patient outcomes.
Transitional Care and the Future of Healthcare
As the healthcare landscape evolves to reward quality over quantity, transitional care programs will further expand nationwide. Their ability to seamlessly coordinate complex care plans, reduce unnecessary utilization, and improve patient well-being makes TCM a win-win for all stakeholders. Healthcare organizations increasingly embed transitional support as a standard part of care delivery.
As transitional care becomes integrated, patients will see fewer complications following medical events. With proper guidance, even high-risk patients can feel empowered managing at home. The future of effective transitional care lies in continued coordination between all partners, advanced digital connectivity, and addressing patients' full range of social and medical needs. As such models spread, the U.S. healthcare system moves closer to true seamless continuity of care.
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