What You Must Know About Transitional Care Management

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Many healthcare organizations are focused on the initial care provided to the patient. However, some patients require more intensive forms of follow-up care, particularly those who are dealing with the long-term consequences of a surgical procedure or a particularly traumatic event. Transitional care management (TCM) aims to address the needs of these patients 30 days after they’ve been discharged from the hospital.

This article will discuss & give a general overview of transitional care management.

Check out this article about implementing chronic care management in your practice!

What Is Transitional Care Management?

Transitional care management was created by the Centers for Medicare and Medicaid (CMS), with the aim of giving patients additional transitional care after they’ve been discharged from the hospital. TCM is concerned with patients who have been discharged from:

  • Inpatient acute care hospital
  • Long-term care homes or nursing homes
  • Inpatient rehabilitation
  • Psychiatric care

Transitional care management initiatives start after the patient has been discharged and continue for thirty (30) days after discharge. TCM initiatives have found success, with one study finding that patients can see up to an 86% decrease in the probability that they will be readmitted to the hospital.

What Are The Components of Transitional Care Management Services?

There are three primary components of TCM: interactive contact, provision of non face-to-face services, and the office visit.

Interactive contact, the first component, happens within 2 days after the patient has been discharged. This contact does not have to be face-to-face, but it does need to happen within the first two days since discharge. This is done in order to make sure the patient is not suffering from any immediate, acute effects after leaving the hospital.

Non face-to-face services are wide-ranging and refer to the services provided to the patient that do not require face-to-face contact with the patient. These include:

  • Physicians providing support to the team by providing education, arranging for resources, referring the patient to specialists, and making sure that the follow ups are scheduled
  • Nurses and nurse practitioners making sure the patient adheres to their treatment
  • All care team members keeping on top of the patient’s care & making sure that the patient is able to access care when needed

The face-to-face visit is required for all patients that need TCM, and depending on the CPT code, it may happen within 7 days or 14 days of discharge. This decision depends on the medical decision complexity, which refers to how difficult it is to establish a diagnosis and/or care management options.

Transitional care management can result in a reduced likelihood of readmission, save a considerable amount of money, and improve the overall quality of care.

Having an accessible patient portal can help with the complexity of administering TCM at your practice. For assistance setting up medical patient portals, give Sequence Health a call at 888-986-3638!

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