Reimagining Patient Journeys With Data-Driven Care Management: Using Transitional Care Management (TCM) Protocols to Reduce Readmissions

Team Innovaccer
Tue 18 Apr 2023
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30 days.

This is a critical time period for patients after being discharged from in-patient settings. For patients, it’s all about recovery, and for providers, it’s all about facilitating that recovery to reduce readmissions. Historically, nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge and up to 76% of these readmissions might be preventable. These readmissions cost Medicare $26 billion of which $17 billion are potentially avoidable.

Reducing readmissions boils down to how patients are monitored, educated, and offered the services required for their recovery. Transitional care management (TCM) encompasses all of these aspects.

What Are Transitional Care Management Protocols and Why Are They Important?

Transitional Care Management (TCM) is a coordinated and continuous process of providing medical care to patients during the transition from one healthcare setting to another. The goal of TCM is to improve the quality of care and patient outcomes, reduce hospital readmissions, and decrease healthcare costs.

The period following hospitalization is a crucial time for patients, as they are at a high risk of developing complications, being readmitted, and experiencing a decline in their health. TCM can help ensure that patients receive the right care at the right time, leading to better outcomes, improved patient satisfaction, and lower healthcare costs.

Why Providers Should Focus on TCM

Many organizations face high costs and diminishing returns due to high readmission rates and risk coding inaccuracy. Health systems can use data, analytics, and technology to streamline care and risk management to help ensure care quality, enhance care coordination, reduce costs and unnecessary utilization, and accelerate innovation.

Physicians that participate in the merit-based incentive payment system (MIPS) program are assessed on the Medicare Spending per Beneficiary (MSPB) measure. This is also significant for hospital networks, as it is used to measure overall hospital costs.

Readmissions—where TCM protocols can have a direct impact—are also measured as part of MIPS and hospitals’ value-based purchasing. Every provider organization must enable their physicians and care teams with all the tools necessary to ensure that TCM services are executed, with all the needed information and adherence to quality standards. A successful TCM program can facilitate better outcomes not just for patients but for providers as well.

Better Outcomes for Providers

  • Drive improved coordination through health information exchanges (HIE) or with the care manager
  • Enhance the visibility and awareness of discharged patients with improved documentation of transitions and associated patient care
  • Reduce costs such as ED costs and related costs with avoidance of inappropriate admissions and improve revenue growth**
  • Enable risk stratification and improve risk coding accuracy
  • Improve physician engagement, save time, and reduce burnout with point-of-care insights and a 360-degree patient view

Comprehensive Care for Patients

  • Decrease risk of inappropriate readmission to the hospital and attendant burdens and costs
  • Enhance satisfaction with the care at the transition from inpatient to PCP
  • Accountable care journeys by educating patients about neccesary steps during recovery period such as medication adherence
  • Improve patient data access to drive positive and engaging patient experiences

Implementing TCM Protocols: What’s Standing in the Way?

Data-Driven Challenges

Data silos and operational inefficiency, due to a lack of standardized forms of storing and sharing data, make it difficult for care teams to track individual patient journeys at the point of care. Without a unified patient record, care teams struggle to generate actionable insights at the point of care, and stratify the population by multiple risk factors, initiatives, and demographics. To effectively carry out TCM services, providers need a 360-degree view of the patient, where all the information—medical history, discharge details, medication reconciliation, etc.—is unified and made accessible at their fingertips to make the right intervention at the right time and deliver personalized care experiences.

Care Coordination Challenges

With increasing care gaps and the lack of automated worklists, care managers struggle with the manual administrative burden of compiling reminders and confirmation texts, looking for patient information, and sending messages to patients and other members of their team. With little or no access to quantifiable reports that measure the impact of care management activities, care teams struggle to track the efficacy and efficiency of TCM programs. Additionally, barriers to communication between providers and patients result in low adherence to clinical appointments, annual wellness visits, and medication plans.

The answer to these challenges are data-driven and automated TCM protocols that provide a framework for comprehensive care coordination and management. With smart TCM protocols, healthcare providers can ensure that patients receive the appropriate care and support during the transition period, including medication reconciliation, patient education, and follow-up care. This can help prevent complications, reduce hospital readmissions, and improve patient outcomes.

Innovaccer’s Data-Driven and Automated Approach to Transitional Care Management (TCM)

Enabling end-to-end healthcare data integration is the first step to enable smooth care delivery, as data is required to perform any type of analytics, including risk stratification. Healthcare organizations must collect data from multiple sources and integrate them into a standardized format. Having access to accurate, complete, and timely data from all relevant sources is a crucial starting point for care teams to access actionable insights and intelligent workflows to manage various protocols.

Innovaccer’s transitional care management (TCM) solution provides automated alerts that empower providers to focus on patient recovery instead of follow-up reminders and appointment scheduling. These TCM protocols are customizable according to the business requirements, for example, health systems can ensure there are separate TCM protocols for hospital discharge and ED discharge.

Innovaccer’s care management applications, such as InNote, InCare, and P360, are all powered by the industry-leading healthcare data and analytics platform. Now providers can identify high-risk patients using predictive analytics at the point of discharge, and reduce readmissions by analyzing ADT feeds, claims profiles, and SDoH data to suggest targeted interventions.

CMS mandates a set of services be fulfilled by providers to ensure the patient’s transition to outpatient settings is monitored effectively, based on which providers receive incentivized payments. Innovaccer can help health systems at every step of TCM implementation.

Mandatory TCM Components

During the first 30 days, starting on the date the patient is discharged from an inpatient setting, the provider must furnish the following TCM components.

  1. Interactive contact must be made within two days of discharge via telephone, email, or face-to-face.
  2. Non-face-to-face services include obtaining and reviewing discharge information, reviewing pending diagnoses, educating patients, supporting treatment and medication adherence, and assisting patients in accessing required community resources.
  3. Face-to-face visits (or telehealth services) within certain timeframes for CPT codes 99495 and 99496.

How Can Innovaccer Help?

As soon as a patient is discharged, TCM protocols are generated and assigned to a case manager.

Case managers (depending on the organization) receive the notification to start TCM services with a 360-degree view of patients.

  1. Care teams can automate notifications to be received by a designated member to initiate interactive contact.
  2. Care managers can analyze patients’ details, such as discharge information, and conduct further assessments through chart reviews, identification of care gaps, and reviewing SDoH to identify a patient's exact needs during the transition.

    With EMR write-back capabilities, care managers don’t need to switch between applications to keep everyone informed about the progression of the TCM program.

  3. Automated notifications for PCP visits within 30 days for further diagnoses and medication reconciliation.

    After the face-to-face visit, the case manager can schedule follow-ups based on the patient’s condition.

Transitional Care Management (TCM) protocols can play a vital role in reducing hospital readmissions, improving patient outcomes, and lowering healthcare costs. By following TCM protocols, healthcare providers can ensure that patients receive the appropriate care and support during the transition period, leading to better outcomes and higher patient satisfaction.

With the increasing focus on value-based care and patient-centered healthcare, TCM protocols will remain become an integral part of healthcare delivery today and in the future.

Learn more about how Innovaccer’s industry-leading healthcare data platform can help you accelerate your transformation by visiting or scheduling a demo with our healthcare experts.


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