What is Transitional Care Management?
Transitioning from a hospital or other care facility back home can be a vulnerable time for patients. That’s where Transitional Care Management (TCM) comes in. TCM is a set of services designed to improve care coordination for patients moving between healthcare settings and their homes.
The main goals of TCM are to improve patient outcomes, reduce the likelihood of hospital readmissions, and ensure patients receive the right care during these critical transitions. In other words, TCM helps people get the care they need, when they need it, so they can stay healthy and avoid unnecessary hospital visits.
In this article, we’ll take a closer look at what Transitional Care Management services involve, how they’re billed, and how they can be implemented effectively. We’ll also explore the importance of care coordination and patient education in ensuring a smooth and successful transition home.
What is Transitional Care Management (TCM)?
Transitional Care Management (TCM) describes a specific set of services designed to improve care coordination for people with Traditional Medicare. It’s all about making sure patients get the support they need in the 30 days after they leave a hospital or skilled nursing facility. The goal is to prevent readmissions and improve overall health outcomes.
So, who provides TCM services? It’s typically physicians, but also certain non-physician practitioners (NPPs) can offer it. This includes Nurse Practitioners (NPs), Physician Assistants (PAs), Certified Nurse Midwives (CNMs), and Clinical Nurse Specialists (CNSs).
What does TCM actually involve? The key components are:
- Quick Contact: Reaching out to the patient within two business days of their discharge.
- A Face-to-Face Visit: Scheduling an in-person appointment relatively quickly – usually within 7 to 14 days, depending on how complex the patient’s medical needs are.
- Complex Decision-Making: Focusing on patients who need moderate or high levels of medical decision-making to manage their health.
Key components and processes of TCM
Transitional care management involves several steps and actions that are designed to make the transition from a facility to home as smooth as possible for the patient.
Initial contact and assessment
Within two business days of discharge, a member of the care team will contact the patient or caregiver to assess any immediate needs or concerns. This contact sets the stage for developing a comprehensive care plan. Scheduling a face-to-face visit is also important and should take place as soon as possible, even before discharge, if that can be arranged.
The face-to-face visit
The in-person visit is designed to review the discharge plan, medications, and follow-up care instructions. It’s also a time for the patient and caregiver to ask questions and voice any concerns. For CPT code 99495 (moderate complexity), the visit should happen within 14 days of discharge. For CPT code 99496 (high complexity), it should take place within 7 days.
Ongoing care coordination
TCM requires ongoing communication between the hospital, the patient’s primary care physician, specialists, and other involved parties. It’s also important to confirm the patient has all necessary medications and understands the dosage, frequency, and potential side effects. Journaling about medication adherence and any side effects is also encouraged.
The Care Transitions Model (Coleman’s 4 Pillars)
The Care Transitions Model, developed by Mary Naylor and her team at Penn Nursing, aims to improve patient outcomes through organized support during those critical hand-off periods.
The model rests on four key pillars:
- Medication Management: Making sure patients understand their medications and take them correctly.
- Health Records: Helping patients keep track of and understand their medical history.
- Follow-up Appointments: Scheduling and attending any necessary follow-up appointments.
- Patient Knowledge of Red Flags: Teaching patients and their caregivers how to spot early warning signs that something might be wrong.
This model emphasizes the importance of involving both the patient and their caregivers in the process. Caregivers need to be available and willing to provide assistance, and it’s important to connect them with resources if they need extra support.
Why is Transitional Care Management important?
Transitional Care Management is important for a lot of reasons:
- It lowers readmission rates. Research has found that TCM helps keep patients from being readmitted to the hospital. This saves money and is better for the patient’s health.
- It decreases medical errors. When patient care is coordinated well, there is a lower risk of mistakes with medications and other problems.
- It improves patient satisfaction. Patients feel like they have support and are more confident in taking care of themselves when they leave the hospital.
- It improves communication. TCM helps doctors and patients talk to each other better.
- It supports people with long-term conditions. TCM is especially helpful for patients who have chronic illnesses.
Billing and Coding for TCM
If you’re a healthcare provider, you’ll use specific Current Procedural Terminology (CPT) codes when billing for TCM services. These codes help define the level of care provided.
- CPT code 99495: Used for cases with moderate medical decision complexity.
- CPT code 99496: Used for cases with high medical decision complexity.
There are some rules to keep in mind when it comes to billing. Only one provider can bill for TCM services for a single patient within a 30-day period. While you can bill for TCM alongside some other care management services, you can’t bill for it during post-operative periods.
Good documentation is essential. Your Electronic Health Record (EHR) needs to clearly show the dates of service and the complexity of the medical decisions made. Make sure to document all the services you provided, as well as any communication you had with the patient and other members of their care team.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) have their own specific billing rules to keep in mind for TCM and other services.
How does transitional care management work?
TCM requires a team effort. To do it right, you’ll need buy-in from leadership, doctors, nurses, and your coding and billing departments. You may need to redesign your existing workflows.
It’s also important to educate patients. Before they leave the hospital or skilled nursing facility, explain the benefits of TCM and let them know if they’ll have any out-of-pocket costs.
Clear communication is essential. You should have systems in place to notify the patient’s primary care provider (PCP) when they’re admitted to acute care and when they’re discharged.
Finally, you’ll want to integrate TCM documentation into your electronic health record (EHR) system. This makes it easy to track and manage patients throughout the transitional care period.
Conclusion
Transitional care management offers a number of benefits, including fewer hospital readmissions, better health outcomes for patients, and smoother care coordination.
But to make TCM work the way it should, it’s important to implement and bill for it correctly. That means documenting everything accurately and making sure the different departments involved are working together.
When done well, TCM can improve the quality of healthcare overall, leading to a healthcare system that is more patient-centered and efficient.