Transitional Care Management

Transitional care management (TCM) refers to a structured approach ensuring the smooth transition of patients from one healthcare setting to another, typically from an acute inpatient facility to outpatient care. This process is particularly vital for patients with chronic conditions or complex health needs, as they are at higher risk during such transitions.

During the process, healthcare providers, particularly primary care physicians (PCPs), address gaps in care that arise due to factors like inaccessible medical records, unclear discharge plans, or limited communication between healthcare teams and patients. The aim is to bridge these gaps to facilitate consistent monitoring and management of chronic conditions, ensuring patients receive appropriate care post-discharge.

TCM protocols involve multiple steps, including prompt communication with patients or caregivers within 48 hours of discharge, scheduling follow-up visits within 7 to 14 days, and discussing all the details of care plans. Medicare and Medicaid have recognized the importance of TCM and have provided reimbursement for these services since 2013.

These services extend for 30 days post-discharge, incorporating both face-to-face visits and non-face-to-face services such as discharge information review, patient education, and communication.

Direct communication with patients or caregivers is required within two business days post-discharge to address patient status and needs.

• It must be performed by clinical staff who can address patient status and needs beyond scheduling follow-up care.
• The service must be reported if two or more unsuccessful contact attempts have been made in a timely manner.

This includes medically reasonable and necessary services provided by clinical staff within the 30-day TCM service period.

• The clinical staff (as appropriate) must provide patients with medically reasonable and necessary non-face-to-face services within the 30-day TCM service period.
• Clinical staff under the clinic’s direction may provide certain non-face-to-face services.

Face-to-face visits are required within specific timeframes based on the complexity of medical decision-making.

• The patient must have a face-to-face visit with a physician or a qualified physician practitioner.
• The timing of the visit and the level of medical decision-making are then applied to determine whether the provider should submit the 99495 or 99496 code.
• If the patient is seen within 14 calendar days of discharge and moderate complexity medical decision-making is documented, the 99495 code may be billed. If the patient is seen within seven calendar days of discharge and high-complexity medical decision-making is documented, the 99496 code may be billed.

• A major challenge in ensuring continuity of care across healthcare settings is the effective communication of information between care providers and institutions.
• This includes advising care providers of the patient’s home medications upon their admission to the new institution, as well as reconciling the patient’s medications upon discharge, ensuring that the patient has access to medications and medical supplies at home, using health information technology (HIT) to ensure that providers have access to complete care plans, and providing adequate patient education.
• Failures in these key areas can lead to negative outcomes and disrupt the patient’s healthcare journey.
• By providing comprehensive care during the transition period, hospital readmissions are reduced and patient outcomes improved.

Readmission risk reduction is one of the important outcomes of TCM, and an under-appreciation of care experiences may inhibit our understanding of the benefits of interventions.
• Decreased mortality rates and healthcare spending post-TCM implementation are risks.
• Increased revenue for healthcare providers due to higher reimbursement rates for TCM services can be a benefit compared to regular office visits.

The future of TCM revolves around advancing communication between healthcare settings, optimizing medication management, and leveraging technology for comprehensive care planning and patient education. This involves enhancing interoperability to seamlessly share patient information, ensuring medication reconciliation at every transition point, and harnessing health information technology for streamlined care coordination. By addressing these challenges, TCM aims to further reduce hospital readmissions, improve patient outcomes, and strengthen reimbursement models for healthcare providers.