What is Transitional Care Management?

Transitional Care Management (TCM) is the management of patient transitions between settings of care, including the transition back home. This article outlines the key components, goals, and impact of adequate transitional care.

To provide a more comprehensive answer to the question “what is transitional care?” we sat down with subject matter experts and team members Evan Carter, Senior Director and program manager, and Senior Manager Aaron Parsons.

Defining Transitional Care Management

Transitional care management is a concept as well as a billing code. Transitional care management as a concept is the marrying of what happened during a post-acute or acute encounter with the longitudinal health status of the patient.

“Transitional care management is care coordination,” says Carter. “It’s calling the patient and saying, ‘Are you okay? What medication did they give you? Are you having trouble with those?’ It’s very much the same workflow/process as care coordination.”

Recognizing the role of timely follow-up with one’s primary care physician in improving health and reducing readmissions, Medicare began paying for TCM services in 2013. As a Centers for Medicare & Medicaid Services (CMS) billing code, TCM provides financial incentives for qualified providers to perform the required transitional care services within a 30-day period. These services include:

• Supporting the patient’s transition to the community setting
• Health care professionals accepting patient care at post-facility discharge without a service gap
• Health care professionals taking responsibility for patient’s care
• Moderate or high-complexity, medical decision-making for patients who have medical or psychosocial problems

Who Plays a Role in Transitional Care Management?

The Primary Care Provider’s (PCP’s) Role

As the assumed expert on a patient’s longitudinal record, the PCP typically leads the charge in managing transitions of care. Their role is essentially to engage the patient and check in with them after their hospital/post-acute stay.

“After a hospital stay, patients are more likely to answer the phone if it’s their primary care provider calling, instead of their health plan, because the assumption is that their health plan is calling with a bill,” said Carter. “Their primary care provider also has that historical knowledge of the patient.”

By playing an active role in the management of their patient’s care, the PCP is able to identify and address any potential risks that could result in hospital readmission.

Benefits of Transitional Care Management for PCPs

Besides improving patient outcomes, transitional care management can benefit the PCP by:

• Increasing referrals and patient satisfaction
• Reducing penalties from Medicare for excessive hospital readmissions
• Using a CPT code for Medicare patients for additional revenue from reimbursements

“It’s not just the right thing to do for their patients — the idea of the billing code was to make it a more appealing activity for the provider, giving them additional incentives for improved care transitions,” said Parsons.

The Health Plan’s Role

While the PCP has the historical knowledge of the patient, the health plan has the resources needed to make transitional care management easier and more impactful for the patient. For example, if a patient is unable to drive themselves to a follow-up appointment with their PCP, their health plan has the resources to assist them with transportation to doctor’s appointments and could proactively reach out and offer this service.

“While the provider has more longitudinal context and may have a better basis of trust, the health plan has more resources to facilitate TCM services,” said Carter. “The health plan brings to bear additional resources that the provider may not have in terms of transportation, education, and outreach.”

PCPs and health plans have complementary strengths in terms of their roles in TCM. As such, there shouldn’t be a line of demarcation — they should be working in tandem.

What is Transitional Care Management’s Goal?

The primary objective of transitional care management is to ensure successful transitions from one care setting to the next and ultimately to promote the best health outcomes possible for patients. These efforts can also help to reduce hospital readmissions by reducing gaps in care and ensuring patients have the support they need following a discharge.

“Poorly managed transitions correlate with poor outcomes, but TCM is helping fix that,” said Parsons. “When TCM activities are undertaken, there are positive outcomes for patients, but when TCM doesn’t happen, those are the gaps that patients fall through.”

Studies have found that approximately one-quarter of readmissions may be preventable. In one observational study, of a total of 1,000 general medicine patients who were readmitted within 30 days, 269 were determined to be potentially preventable because of “gaps in care during the initial inpatient stay.” Another meta-analysis on causes of readmissions  found that 27% of readmissions in a range of studies were potentially avoidable. This shows where the need for transitional care management comes from, and how it can be an effective strategy to reduce readmissions.

“These gaps are both a problem and an opportunity that can be solved by the move toward value-based care, the creation of new billing codes, and the health IT that supports TCM alignment,” said Parsons.

How to Improve the TCM Process

To help ensure successful transition care management between health care settings, the PCP needs to have access to a patient’s discharge summary. Obtaining this information usually requires the provider to monitor several different channels, which is a tedious and time-consuming process. Accountable Care Organizations and other entities in the care coordination chain that benefit from TCM rely on clinical coordination software that automates this process by delivering comprehensive clinical documents triggered by hospital discharge alerts.

Admission, discharge, transfer (ADT) can improve transitional care coordination by keeping PCPs informed through real-time encounter alerts. This helps ensure the PCP is able to follow up with the patient, resulting in reduced hospital readmissions and an increase in TCM revenue. To demonstrate how providers can leverage health IT to improve TCM, in Florida, the Palm Beach Accountable Care Organization (PBACO) worked with the state’s health information exchange (Florida HIE) to receive ADT data feeds. PBACO providers were notified when their Medicare patients were admitted, discharged home or transferred to another healthcare facility to increase follow-up communication and visits. This allowed PBACO to capture 10% more TCM revenue opportunities across all discharge types, which generated $30 million in savings. More importantly, by providing better coordinated care, PBACO’s patient satisfaction rate increased to 96.2%, and they were ranked #4 out of 37 ACOs in Florida for quality of care.

This article was originally published by Audacious Inquiry, now a part of PointClickCare.