How To Improve Transitional Care Management

How To Improve Transitional Care Management

Maintaining low patient readmission rates is critical for a healthcare service provider. High readmission rates can strain your resources, such as beds, staff time, and medical supplies. Additionally, having excessive patient readmission rates can attract penalties under the Hospital Readmission Reduction Program (HRRP).

To avoid such eventualities, healthcare institutions need to have a seamless transitional care management (TCM) plan.

What Is Transitional Care Management?

Transitional care management is a coordinated healthcare program that helps transition patients from a hospital environment to their communities. It aims to identify, evaluate, and mitigate issues that may hinder successful transitions.

Transitional care management is a collaborative process that requires communication between healthcare service providers, patients, and their families. When done correctly, it can improve patient outcomes and reduce the likelihood of readmission. Some of the vital components of transitional care management include patient engagement, medication management, and continuity of care.

Guide to Improving Transitional Care Management

Considering how costly patient re-hospitalizations can be, an effective transitional care management strategy should be a top priority. Here is a five-step approach to help boost your transitional care management efforts.

Assessment and Planning

Start by assessing patients’ needs and preferences as soon as they’re admitted, paying close attention to factors like their medical history and the presence (or lack) of a social support system. Develop individualized care plans in collaboration with patients and caregivers, outlining goals, interventions, and follow-up care requirements.

Medication Access and Adherence

Educate your patients and/or their caregivers on the medication regimen they’ll be using once the patient is discharged. Ensure they understand the medicine given, the right dose, and how long they’ll take it. It’s equally important to verify whether patients can access and afford all the medications they need.

Follow-Up Visits

Once your patients leave the hospital, organize to have them attend follow-up appointments within 7–10 days from the discharge day. Follow-up visits will help you monitor progress, address any emerging issues or complications, and confirm their adherence to prescribed medications.

At-Home Care

At-home care involves providing medical, rehabilitative, and supportive services to patients in their own homes following discharge from a healthcare facility. If your patients are in a weakened state following treatment, they’ll need someone to check on them and provide daily support with tasks like cooking, cleaning, and grooming. As a transitional care manager, you’ll determine the kind of support your patients need and ensure they are placed with the right service providers before discharge.

Ask Patients To Recall the Plan in Their Own Words

This step allows you to confirm if the patient has understood the discharge plan, medication regimen, and available at-home support services.

Applying these strategies will help you create better patient outcomes and reduce readmissions in your organization. In case you need further assistance in improving your transitional care management services, do not hesitate to contact Sequence Health today.