Transitional Care Management Service: Bridging The Gap Between Care Settings

Transitional Care Management Service

What are TCM Services?

TCM services are clinical services provided by clinicians such as physicians, nurse practitioners, clinical nurse specialists, and physician assistants during care transitions from one care setting to another. The goal of these services is to help ensure the safe handoff of a patient from one level of care to another and bridge the gaps that often occur during transitions.

Why are TCM Services Important?

Transitional Care Management Services  ransitions are particularly vulnerable periods that can lead to medical errors, rehospitalizations or other adverse events if not properly managed. Studies have shown that around 20% of Medicare patients discharged from a hospital are readmitted within 30 days, often due to post-discharge complications or a lack of follow-up care. Transitional Care Management Services aim to address key issues like medication reconciliation, patient education and ensuring follow-up care is set up to occur as planned. This helps reduce unnecessary healthcare utilization and associated costs. For patients, it can improve outcomes and reduce stress associated with changes in care settings.

Elements of a TCM Visit

A TCM visit typically occurs within 14 days of discharge from an inpatient stay and includes the following key elements:

- Comprehensive medication reconciliation and management - This involves reviewing and addressing any discrepancies or duplications in a patient's medication regimen in order to prevent issues.

- Patient education and self-management support - Patients and their caregivers receive guidance on their condition and treatment plan as well as instructions on any warning signs to watch out for that may require follow-up.

- Medical/social needs assessment - The clinician assesses any ongoing medical, psychosocial or functional needs the patient has and refers them to appropriate resources or services as required.

- Communication with other care providers - Phone calls or written summaries are provided to convey key patient information to the receiving providers and ensure a seamless transition of care.

- Scheduling of follow-up appointments - Follow-up medical appointments, diagnostic tests or other services are scheduled and confirmed to ensure patients receive ongoing care as planned.

- Medication management for financial/access issues - Assistance is provided to address any barriers to filling or taking medications as prescribed due to cost or other access issues.

Benefits of Transitional Care

When transitional care services are properly implemented, some key benefits that can result include:

- Reduced hospital readmissions - By addressing issues that could potentially lead to hospital readmission like medication or care plan follow-through, readmissions are less likely to occur. Studies have found Transitional Care Management Services can cut 30-day readmission rates by 25-50%.

- Improved patient satisfaction - Patients feel more supported and confident in managing their own care at home when care transitions are well-coordinated. This leads to higher satisfaction scores.

- Cost savings for the healthcare system - Fewer preventable readmissions translates directly into lower healthcare costs. When readmissions are cut, millions of dollars can potentially be saved annually.

- Better health outcomes long-term - With proper transitional support, patients are empowered to adhere to treatment plans which leads to better management of chronic conditions long-term.

Reimbursing for Transitional Care

The Centers for Medicare & Medicaid Services (CMS) began reimbursing clinicians in 2013 for providing Transitional Care Management Services through two billing codes: 99495 and 99496.

99495 is for a TCM visit within 14 days of discharge that lasts at least 30 minutes by the clinician or clinical staff under their direction.

99496 is used for a visit within 7 days of discharge that lasts at least 30 minutes with moderate or high medical decision complexity.

Eligible discharges include patients with multiple chronic conditions treated with 5 or more medications to align with patients most likely to benefit from transitional support.

The reimbursement rates have continued increasing, reflecting TCM's importance. In 2022, CMS will pay $171.76 for code 99495 and $228.32 for 99496, making transitional care a viable service line for practices.

Role of Healthcare Organizations

While individual clinicians play a key role in coordinating transitional care through the required visit, successful programs require participation across various provider settings. Hospitals can implement policies and programs like:

- Sending discharge summaries electronically to primary care providers promptly.

- Ensuring patients have follow-up visits scheduled before leaving the hospital.

- Partnering with outpatient facilities to streamline referrals for services.

- Using transitional nurses or coaches to follow up on high-risk discharged patients.

- Standardizing the transfer of care process through checklists and other protocols.

Primary care practices can also optimize their roles by:

- Designating staff to coordinate closely with hospitals on incoming patients.

- Facilitating timely follow-up post-discharge through open appointment access.

- Utilizing nurses and pharmacists as part of the transitional care team.

- Integrating community resources and services into the transition plan.

When all stakeholders work collaboratively with a goal of providing smooth handoffs, patients benefit greatly through safer, higher quality care transitions. Proper transitional care management has been shown to save lives as well as healthcare dollars.

Get More Insights, Transitional Care Management Service