Transitional Care Management: What It Is & How To Work With Your Team

• Transitional Care Management (TCM) is a service that helps people with chronic healthcare conditions make the transition from the hospital to a community setting easier. 
• The goal of TCM is to prevent potential hospital readmissions and ensure that there are no gaps in a patient’s care.
• TCM is a service provided by Medicare, but some private insurers may also cover it. 

At the end of a hospital inpatient stay, someone often has follow up care appointments and home health steps to take. To ensure a smooth transition, patient satisfaction, and improved overall health outcomes, discharged patients may be assigned a transitional care team.

Within about two business days, someone from the TCM team may be in touch for a timely follow up. This could include help coordinating care with other providers, assistance with documentation requirements, and initiatives to educate patients on discharge information and community resources that may improve outcomes and reduce unnecessary readmissions.

Here’s everything you need to know about TCM requirements and how working with this time may help in high complexity cases.

Transitional Care Management (TCM) is a service created by the CMS (Centers for Medicare and Medicaid Services) to help ease the transition for those with chronic medical conditions between an inpatient hospital stay and coordinated regular treatment in a patient’s community setting, such as at home or in an assisted living facility. The goal of TCM is to ensure there aren’t gaps in a patient’s care after leaving the hospital. The TCM service occurs for 30 days, starting on the day of discharge from the hospital.

Parts of TCM

TCM services are comprised of a few different parts, including:

• Coordinated care between healthcare providers
• Medication management and review
• Patient and caregiver education
• Care management and planning for the future

These parts can occur through different forms, including face-to-face visits, interactive contact, and non-face-to-face services.

Why Do You Need Face-To-Face Visits and Non-Face-To-Face Visits?

Patients undergoing TCM care require face-to-face visits as well as non-face-to-face visits and services. The specific types of visits and how often they will occur vary on the patient’s specific condition and treatment plan, but both types of visits allow a more comprehensive range of care. 

For example, face-to-face visits allow healthcare providers to ensure that the patient’s medication log has been reviewed and, if necessary, updated to reflect any changes. Only one face-to-face visit is usually required during the TCM period.

Non-face-to-face visits allow patients and caregivers to be given access to important information, such as health resources or self-management education regarding their condition(s). Rather than relying solely on an in-person visit, these services can help the patient and caregiver better manage the patient’s health on their own. Telehealth services are often more common than face-to-face interactions to increase access to information and care surrounding the patient’s recovery. Non-face-to-face services must be provided, unless the healthcare provider deems it medically unnecessary for the patient. 

Who Performs TCM?

According to the CMS, the list of healthcare professionals and clinical staff who can perform TCM services includes:

• Physicians (any specialty, including family physicians or the patient’s primary care physician)
• Non-physician practitioners (NPPs) who are legally authorized and qualified to provide the services in the state where they practice.
• Certified nurse-midwives (CNMs)
• Clinical nurse specialists (CNSs)
• Nurse practitioners (NPs)
• Physician assistants (PAs)

Transitional care management (TCM) is intended to reduce potentially preventable readmissions and medical errors during the 30 days following discharge from acute care. TCM provides a few benefits, including:

• Lower likelihood of hospital readmission: While many chronic conditions can be treated at home, occasionally, a patient may need to be admitted to the hospital for certain treatments. The potential disruption of care between the inpatient visit and readjusting to a community setting can often result in readmissions and other medical issues. TCM helps ensure no gaps in care, making hospital readmission and mortality less likely.
• Lower healthcare costs: TCM ensuring fewer hospital readmissions can lower healthcare costs for patients by not adding additional hospital charges to their medical bills.
• Help with health management: TCM helps patients with chronic conditions, such as dementia, heart disease, COPD, and diabetes, manage their health during the transition period. TCM reduces the likelihood of readmission and ensures patients receive necessary care in their community setting.

To qualify for TCM services, a patient must meet the following requirements:

• Be discharged from a qualifying service setting: this can include a skilled nursing facility, inpatient acute care facility, partial hospitalization, hospital outpatient observations, or inpatient psychiatric facility.
• Have documented medical records indicating need: medical records must show that the patient requires care or extra support from a physician or other non-physician member qualified to perform these services.

The type and amount of care for patients who need transitional care management services will vary by person, based on the number of diagnoses, the complexity of medical records and conditions, and risk factors associated with the patient’s medical conditions.

TCM services are timed to ensure the most effective care and treatment is provided for the patient based on their needs. Overall, TCM service timelines tend to follow this order:

First 48 Hours 

Within the first two days of discharge, the physician(s) or healthcare provider providing the services must contact the patient (or caregiver) to check-in. This initial contact ensures that the patient is adjusting, understands their medications, and has no immediate concerns. This contact does not have to be in person and usually takes place over the phone or through email.

First 7 Days or 14 Days

After the first few days after discharge, the primary care provider or other qualified physician determines medical decision-making choices for the patient. For patients with higher levels of complex medical issues, a face-to-face visit occurs within 7 days of discharge or 14 days for those with moderate or lower levels of medical issues. This visit allows the physician to see if the patient is recovering well, answer any questions or concerns about medications/​treatments, and review medications to ensure they work properly. The face-to-face visit cannot occur on the same day as the discharge day management services (the same day the patient is discharged).

Up to 30 Days

The remainder of the 30 days involves monitoring from physicians and approved staff to ensure proper care management, answering any questions, and adjusting treatment plans. Referrals to specialists, tests, and appointments are likely to occur during this period.

Whether insurance covers TCM services depends on the provider and their specific policy coverage. However, many insurance options are likely to provide some level of support for these services.

Medicare

Medicare beneficiaries, especially those at higher risk of readmission or with complex medical requirements, are usually covered for TCM services, as they are eligible under Medicare Part B. However, coverage should be verified to ensure service qualifications are met.

Private Insurance

Some private insurance companies may cover TCM services, but it will vary by insurance provider. However, patients may have to obtain pre-authorization for the specific care before the company will choose to bill TCM services.

As senior patients begin their recovery after discharge, it’s not uncommon for caregivers to step in to help them navigate the specifics of TCM. However, knowing what questions to ask and what information is needed can be daunting for caregivers and patients. A few questions you can ask your TCM healthcare provider include:

• How do I contact the healthcare team/​physician in charge of TCM services?
• What medications are being prescribed, and what is the medication schedule/​dosage to administer?
• What can we expect after discharge from the hospital?
• Are there any activities or tasks to avoid? What tasks may be more difficult and will require help?
• When are visits scheduled to occur?
• Is there any medical equipment that is needed after discharge?
• What resources or services are available to me?

Feel free to ask your provider or healthcare team about any concerns or questions. The goal is to ensure you and the patient understand their care and peace of mind as they transition from the hospital to a home or community setting.