A Guide to Transitional Care Management

Chronic medical conditions such as heart disease, diabetes, dementia, COPD, and others require a transition period between the in-patient phase and the patient settling into care at home. The same is true for major surgical procedures.

Transitional care management provides consistent after-discharge care to both groups of patients to avoid a relapse or readmission.

What Is Transitional Care Management?

Transitional Care Management (TCM) services facilitate the hand-off of patients from an inpatient facility to their community or family setting.

Designed to last for 30 days, TCM allows the healthcare provider to guide the patient and family on the road to recovery while minimizing the chances of relapses occurring.

1. TCM usually falls into 3 broad categories:
2. Interactive communications
3. Non-face-to-face service delivery
4. Face-to-face visits

Interactive communications are made within the first two days of discharge to ascertain the status and transitional needs of the patient. Healthcare call centers are key solutions in carrying out this stage of TCM. The results of the call can then be, face-to-face visits are carried out seven to 14 days after discharge.

Non-face-to-face service delivery fills in the intervals between in-person visits. They can be carried out via phone call or medical patient portals.

What Is the Purpose of TCM?

The purpose of TCM is to aid the at-home caregiver and the patient in the following areas:

1. Reviewing discharge information
2. Management of medicines and assistance with prescriptions
3. Education and support regarding the treatment regimen and recommended daily activities
4. Assistance in scheduling appointments for follow-up checks or tests
5. Assessment of the need for additional tests or treatments
6. Liaising between patient and the relevant health care professionals

Who Qualifies For Transitional Care?

Qualifying for TCM is dependant on the facility that discharges you and the recommendations of the attending doctors.

Examples of qualifying service facilities are:

1. Skilled nursing facility
2. Inpatient acute care hospital
3. Hospital outpatient observation
4. Partial hospitalization
5. Inpatient psychiatric hospital

The patient’s medical record must also state that the patient will need aftercare from a physician, clinical staff, or other healthcare providers.

The extent of care providers’ involvement in a patient’s transitional care management is contingent on

1. The risk of serious complications
2. The complexity of medical records and diagnoses made
3. The number of diagnoses
4. Recovery management options

Billing Requirements for Transitional Care Management

Since transitional care management is temporary, the billing is usually submitted by the healthcare provider at the end of the 30 days.

To bill for TCM, a care provider must check off the following criteria:

1. Direct patient contact within two business days of discharge
2. A face-to-face visit within seven or 14 days after discharge
3. Moderate to highly complex medical decision making

As regards insurance, the specifics of TCM coverage vary. The patient needs to find out beforehand monthly premiums, deductibles, and copay amounts related specifically to TCM.

What Is a Transitional Care Hospital?

Patients with complex conditions or who need either an extended recovery period or inpatient rehabilitation are often discharged into a transitional care hospital. They will typically stay in such a facility for upwards of 25 days.

These long-term care hospitals offer more specialized care than what a patient can get in skilled nursing facilities or home care.

Transitional care management is crucial for the seamless recovery of chronic conditions. It improves the quality of life for the patient and prevents costly readmissions. Invest in TCM solutions to help your chronic care management run efficiently.