What are Transitional Care Management Services?

Transitional care management (TCM) services refer to care coordination and medical management provided to patients when transferring between different locations or levels of care, such as when transitioning from a hospital to home or a long-term care facility. Proper transitional care aims to prevent medical errors, reduce unnecessary services like readmissions, and maximize patient outcomes after discharge by ensuring safe hand-offs between care settings and providers.

The Importance of Care Transitions

When patients move from one care environment to another, such as from a hospital to home, there is a risk of medical errors, gaps in care, nonadherence with medications or treatment plans, and poor communication between sending and receiving providers. These problems during care transitions can negatively impact patient outcomes and quality of life. They are also costly - estimates suggest nearly 20% of Medicare beneficiaries discharged from hospitals are readmitted within 30 days, costing over $26 billion annually due to potentially preventable readmissions alone. Effective transitional care programs aim to improve outcomes and lower costs by facilitating a safe transition of care.

Elements of Transitional Care Management

Transitional care management Transitional Care Management Services incorporate several core elements to promote safe and effective care transitions. Within the first 14 days post-discharge, a physician or qualified non-physician practitioner evaluates the patient's transition of care needs through communication with inpatient providers and the patient themselves. A comprehensive care plan is developed that addresses medications, pending diagnostic tests and treatments, equipment needs, and follow-up appointments. Through telephone calls, telehealth visits, or in-person encounters, the TCM provider ensures the patient understands the plan of care, and monitors for problems or changes in condition during the transition period. Crucial communication also occurs between the TCM provider and any post-discharge practitioners involved in the patient's ongoing care.

Billing for Transitional Care Management

Under current Medicare rules, physicians and non-physician practitioners can bill for transitional care management (TCM) services using specific evaluation and management (E/M) CPT codes. For a moderate or high complexity level of medical decision-making during the service period, CPT code 99495 (for the initial TCM service within 14 days of discharge) or 99496 (for additional TCM services beyond the initial period) would be appropriate. Modifier -25 indicates a stand-alone TCM visit occurring within 14 days of discharge that did not result in a related E/M service payable under other codes. These transitional care management codes help recognize the importance of care coordination activities during a crucial post-discharge period for patients.

Types of Facilities Utilizing TCM

Transitional care management (TCM) services have particular relevance in skilled nursing facilities (SNFs), acute rehabilitation facilities, long-term acute care hospitals (LTACHs), and inpatient psychiatric facilities. Patients discharged from these post-acute care settings often have multiple chronic conditions, functional impairments, or mental health needs requiring close care coordination. With payment now available for TCM at discharge from inpatient facilities as well as hospitals, more SNFs, rehabilitation centers, LTACHs and psychiatric hospitals are investing in dedicated transitional care programs. These programs aim both to improve patient outcomes through safe hand-offs, and to lower costs through reduced potentially preventable rehospitalizations.

The Role of Nurses in Transitional Care

Nurses play an integral role in transitional care management (TCM) due to their clinical expertise and relationships with patients. During a patient's inpatient stay, nurses gather assessments, treatment information and discharge instructions that feed into the TCM plan of care. Post-discharge, nurses conduct patient outreach by phone or in person to reinforce self-management skills, review medications, inspect incision or wound sites, and screen for concerns through targeted assessments. Their deep clinical knowledge allows nurses to identify issues early and determine if adjustments to the plan of care or referrals are needed. Many facilities now employ transitional care nurses (TCNs) who specialize exclusively in coordinating care transitions through activities like following patients across all settings from admission to well past discharge.

Measuring Success of Transitional Care Programs

To gauge the success of transitional care management (TCM) programs and identify areas for improvement, healthcare organizations analyze quality metrics like 30-day readmission rates, patient experience survey scores, rates of post-discharge emergency department visits, and percentage of completed recommended post-acute care appointments. Systems conducting robust post-discharge phone calls and follow-up may also measure how many issues were identified during outreach that required intervention, versus patients who remained stable. With access to longitudinal data, trends in outcomes pre- and post-TCM program implementation can show return on investment. Standardized transitional care scores have also been developed to benchmark facilities' performance and level of coordination against evidence-based best practices.

Compliance with Transitional Care Standards

To bolster quality and safety, organizations providing transitional care management (TCM) services must operate according to evidence-based standards. Critical access hospitals and community health centers, for example, may seek "Transitional Care Accreditation" demonstrating competency across core delivery elements. Ensuring medical record documentation meets standards for communication of treatment summaries is also important for compliance and care coordination. Use of standardized transition forms and protocols supports providers in seamlessly handing off patients. Health systems accredited by The Joint Commission undergo rigorous review of transitional care processes, from inpatient discharge planning with patients/families to post-discharge follow-up and readmission risk reduction. Compliance with national standardized transitional care criteria helps maximize appropriate utilization of TCM billing codes too.

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