iPatientCare Blog - Transitional Care Management

Transitional Care Management – An emerging oppurtunity for Healthcare Professionals

What is Transitional Care Management?

The idea behind Transitional Care Management (TCM) is to ensure that there are no gaps in patient care by encouraging providers to take charge of the patient’s care from the time patient gets discharged.

For patients suffering with chronic conditions, transition from hospital to outpatient care becomes a priority, and so CMS encourages more structured approach to transitional care management. It is designed not only for specialists or primary care providers but also for non-qualifying medical practitioners. The transition care can be from any one of the following settings such as:

  • Hospital outpatient observation or partial hospitalization
  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Skilled nursing facility
  • Long-term care hospital
  • Hospitalization at a community mental health center

Requirement for a practice to become eligible for Transitional Care Management?

There are only certain categories of health care professionals such as nurse practitioners, certified nurse midwives, clinical nurse specialists, providers of any specialty and providers’ assistants, who are eligible for TCM.

TCM can be utilized on new as well as established patients too. The initial contact must be made within 48 hours of patient discharge, as engagement with the patient is very crucial after the discharge. So, the follow-up appointment should be within two business days. If by chance, the patient is discharged on Friday, then his/her two business days will end on Tuesday.

If patients are discharged from an emergency department, then they are not eligible for TCM services. Patients are only eligible for these services to help with the transition following discharge from above mentioned facilities. Also patients must be in need of additional support from the healthcare professionals.

What happens after discharge?

A proper documentation is prepared for TCM eligible patients which may include coordinating care with physiatrist and occupational therapy. It also provides the additional education like – instruction on monitoring blood sugar levels or recording daily weights, to the patient and caregiver. This in turn may also include coordinating services with durable medical equipment supplier.

For hospitals, practices, and nursing homes, TCM is important part of their successful discharges. TCM has vital role to play in physician-based programs, only if the providers are willing to participate in it from the beginning.

How billing is done for TCM?

When arranging for reimbursement for TCM, the health care professionals must keep in mind the following:

    • Need to educate patient’s beneficiary, relatives or primary caregiver.
    • Obtain and review the patient’s discharge information.
    • Need to furnish medicine reconciliation and management by the date of the mandatory face-to-face visit.
    • Another requirement is scheduling follow-up visits with various services and providers.
    • The practice may have to establish or re-establish ties with local community providers and services.
    • Keep in mind that all face-to-face visits must occur within one to two weeks, which depends on the complexity of the patient’s situation.

There is additional work required even after the initial call and face-to-face services. In combination with non-face-to-face services, transitional care management is comprised of one face-to-face visit within the specified time frames. This service must be performed by the provider or other qualified health care professionals.

Some of the non-face-to-face services provided by provider or other qualified health care specialists include:

  • Assistance in scheduling all the required follow-up with community providers and services.
  • Obtaining and reviewing the discharge summary, or continuity of care documents.
  • Must know about all the interaction with other qualified health care professionals who assume or re-assume care of the patients’ system-specific problems.
  • Establishing or reestablishing the referrals and arranging for needed community resources.
  • Must review if there is need for follow-up on pending diagnostic tests and treatments.
  • Also educate patient, family, guardian, and/or caregiver.

Some of the non-face-to-face services provided by clinical staff, may include:

  • Assessment and support for treatment and medication management
  • Identification of available community and health resources
  • Provide education to support self-management, independent living, and activities of daily living
  • Communication regarding aspect of care and also with home health agencies and other community services utilized by the patient
  • Also facilitating access to care and services needed by the patient and/or family

How much does transitional care services pay?

Medicare’s allowance does vary geographically and the payment structure also varies from payor to payor. The incentives are based on relative value units and current conversation factor. It depends on the services performed in a non-facility setting and services performed in a facility setting.

The Financial incentives added Transitional Care Management can be quite significant and should not be ignored. Assisting patients and providing them care more smoothly from a hospital, nursing facility, or other qualifying setting is rewarding to both parties in terms of fostering optimal health and wellbeing.

How can the patients improve their own likelihood of safe and effective transitions?

  • Patients can promptly schedule follow-up appointments.
  • They can also talk to their providers or pharmacists about how to take medications.
  • Must also find out what other facilities hospitals offer, such as home visits.
  • Other added services may include free transportation to follow up appointments.
  • Must understand discharge instructions and must keep care takers or guardians at home, thoroughly involved.

It can be difficult to keep up with everything having to do with initiatives of transitional care management; as the continual change in healthcare industry has become a fact of life. Sometimes it is difficult for the practices to meet Medicare’s complex and time-sensitive regulations. The use of a certified EHR, or even better, having a reliable EHR vendor like iPatientCare, whose familiarity with Transitional Care Managment’s nuances can be beneficial for the practice.


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