Care Transition Management and Care Coordination

January 17, 2023

Patients who don't receive proper routine medical follow-ups and checkups after hospital discharge are more likely to experience relapses and complications. It is one of the leading contributors to readmissions rates.

Most likely, a good percentage of patients under your care would need follow-up calls and observation. In the absence of professional management, managing and meeting Transitional Care Management expectations would be a daunting task.

The Centres initiated Transitional Care Management for Medicare and Medicaid Services (CMS). One of the significant functions of Transition care management (TCM) is to provide a healthcare practitioner who will take responsibility for a patient's medical welfare and follow-up needs from the moment of discharge.

By usual standards, Transition Care Management lasts thirty days from the day of discharge. The activities during this period involve a physical meeting and examination of the patients and multiple virtual meetings, e.g., Phone calls, video messaging with the patient.

These activities make the transition of a discharged patient smooth and eliminate gaps in inpatient care. To effectively ensure continuity of care, The assigned medical practitioners should contact the patient within two business days after discharge. You can also make contact at the medical center, provided it occurs after release.

The goal of Transition care management is to reduce relapses and readmissions.

Provider and Patient Requirement 

You should familiarize yourself with the requirements both providers and patients have for transitional care management before taking part in it.

Provider requirement

First, you should be aware that certain types of health care providers can only provide TCM services. These professionals include physicians of all specialties, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physicians' assistants.

In addition, non-physicians must obtain licensure and be legally allowed to practice TCM in the state in which they practice.

Engaging patients after they leave a hospital, nursing home, or other qualifying facility is essential. For this reason, TCM mandates the healthcare provider to follow up within 48 hours after discharge.

Additionally, you should schedule an in-person appointment within a week or two following the patient's discharge, depending on the case's complexity.

It is crucial to keep in mind that electronic health records and EHR applications must be appropriately certified for you to qualify for TCM's CMS reimbursements. It is impossible to take advantage of TCM and generate significant, additional revenue without such an EHR.

EHRs today have many benefits. A certified EHR gives you access to CMS initiatives such as TCM, PCMH, and CPC+, including comprehensive care management (CCM) and patient-centered medical homes.   

Patient requirement

The patient needs to meet specific requirements before they can be involved with transitional care management.

A patient must be discharged from one of the following service settings:

  • Nursing homes
  • Inpatient psychiatric hospitals
  • Inpatient acute care hospitals
  • Rehabilitation facilities
  • Partial hospitalization
  • Long term care hospitals
  • Hospital outpatient observation

Billing Requirements for TCM

You should keep in mind the following billing requirements when arranging reimbursement for the TCM services you provide to patients:

  • Review the patient's discharge information
  • Assess the need for tests and treatments, and follow up if necessary
  • In addition, you will need to adequately inform the patient's beneficiary, relative, or primary caregiver
  • Your organization may need to establish or re-establish relationships with local service providers
  • It is also necessary to schedule follow-up visits with various providers and services
  • The patient must have a personal consultation within one to two weeks, depending on their situation
  • By the date of your mandatory in-person meeting, you will need to provide medication reconciliation and management

In pursuing optimal health and wellbeing, helping patients transition out of a hospital, nursing facility, or similar setting is beneficial to all parties. 

TCM's financial incentives are not to be disregarded, as they can be highly significant. 

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