Health systems are challenged with reevaluating transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients. Care transitions entail moving patients between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness. The settings involved in care transitions include hospitals, nursing facilities, the patient’s home, rehabilitation facilities, home health agencies, primary and specialty care offices, community health centers, community-based settings, hospice, long-term care facilities, and others. Better care transitions have the potential to reduce readmissions—the “back and forth” movement of a patient between these settings and the instability, anxiety, and risks to health this may cause.
One in five Medicare beneficiaries is readmitted to the hospital within thirty days of discharge. Improved care transitions have the potential to reduce readmissions by enhancing communication and coordination among providers and minimizing the discomfort and insecurity among patients. Medicare now pays physicians and other qualified non-physician professionals for post-discharge transitional care management services under CPT codes 99495 and 99496. Transitional Care Management (TCM) care teams can help providers with:
- Medication Reconciliation Follow-up
- Visit Scheduled (as needed)
- Make or Follow-up on Referrals to Post-Acute Care, Community, and other resources
- Health Coaching & Education
- Assistance in Scheduling Face-to-Face Visit within 7 or 14 Days of Acute-Care Discharge
- Help to Arrange Transportation for Patient Face-to-Face Visit
- Post-Visit Follow-up
The coordination of care across the health care continuum is important to the implementation, management, and evaluation of a patient’s treatment plan. TCM care teams work alongside health systems and providers to facilitate transfer and receipt of patient records between different levels of care and locations to ensure continuity. Care Managers working with electronic health records (EHRs) and other technologies can lower the potential for communication breakdowns in these processes. Collaborations between healthcare providers and TCM care managers strengthen the handoff of care plans and patient history promoting more successful treatments.
Successful hospital and health system initiated transitional care programs require a “bridging –strategy” that includes both pre-discharge and post-discharge interventions. Transitional Care Managers can bring together multi-component strategies that include community resources, patient engagement and education, and communication with outpatient providers. Effective care transitions can boost pay for performance and quality measures for hospitals, providers and health systems, namely lowering penalties and improving reimbursement based on readmissions rates. Strong care transitions can also elevate provider image and reputation.
Older adults with multiple chronic diseases, and often several medications and home care concerns require constant monitoring and reporting on progress and changes in their conditions. Transitional Care Managers can help eliminate confusion regarding treatment plans, duplicative testing, discrepancies in medications, and missed physician follow-up. Together, this collaboration eradicates fragmented care and boosts patient satisfaction and quality of life.
Written by Joseph F. West, ScD on Thursday, 15 December 2016. Posted in Discharge Planning, Readmissions, Post-Acute Care, Transitional Care Management, TCM