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Transition Care Management: Transitioning Patients to a New Care Setting

What is transitional care?

The term “transitional care” refers to a range of services designed to promote the safe and timely continuity of care for patients as they move between care settings. High-quality transitional care is especially critical for older adults with multiple chronic conditions and complex, multi-specialty care plans, who require meticulous continuity of care as they move frequently between care settings.

The National Institutes of Health reports that suboptimal “handoffs” of these older adults and their caregivers from hospital to home have been linked to adverse events, low satisfaction, and high rehospitalization rates. Transition Care Management (TCM) improves patients’ quality of life and helps reduce hospital readmission. It also helps to control costs for primary care, emergency department care facilities, long-term care centers, and nursing homes alike.

Caregivers who work at a rehabilitation facility or a skilled nursing facility with especially vulnerable geriatrics patients and their family members need meticulous discharge planning, transitional care, and frequent follow-up visits with family members to prevent hospital readmission.

Why is transitional care important?

The Affordable Care Act established transitional care programs to improve care quality and reduce costs at primary care centers, inpatient clinics, emergency departments, long-term care facilities, and nursing homes. Rehabilitation facility and skilled nursing facility care providers have found that these transitional care programs help post-hospital discharge patients and their family caregivers enjoy better continuity of care and safer transfer between care settings.

The Health Affairs journal reviewed randomized clinical trials of transitional care interventions and care coordination upgrades — like assigning nurse team leaders and visiting discharged patients at home — which demonstrated that TCM leads to reductions in readmissions through at least 30 days after discharge planning.

Improved Care Management is a key focus of health reform. TCM ensures patients receive the care they need from the moment discharge planning begins in a care hospital or other health care facility; it continues for at least 30 days so that the patient can adjust to a new care setting and prevent adverse effects.

Transitional care models

The American Academy of Ambulatory Care Nursing (AAACN) has standardized the Four Pillars of Care Transition Interventions — medication, personal health record, follow-up visits, and red flags — for use in the following transition care models:

Hospital-to-home transitional care

Hospital-to-home transitional care requires preparing the patient for discharge planning and for common post-discharge situations by offering written instructions as well as technical assistance. Every discharge plan must be reconciled with national guidelines. Teaching patients risk-specific interventions and creating an emergency plan is also critical — especially for patients with chronic conditions like heart failure.

Each care team that delivers transitional care and manages discharge planning must provide diagnosis and care plan education (including medication, diet, and exercise) for each patient and their family caregivers. They should also schedule post-discharge appointments and tests before each handoff, and call each patient 2 to 3 days after hospital discharge. According to the AAACN, this model has decreased re-hospitalizations and costs per patient, increasing revenue for primary care clinics, emergency department facilities, care hospitals, nursing homes, and all care settings that practice transitional care.

Clinic-to-home transitional care

Clinic-to-home transitional care requires communities and health care systems to support patients’ self-management efforts with shared decision-making and clearly explained clinical information. This model also leverages the Assessment of Chronic Illness Care (ACIC) and Patient Assessment of Care for Chronic Conditions (PACIC), which have improved the well-being of patients with asthma, diabetes, cancer, comorbid depression, and bipolar disorder.

Nursing-home-to-hospital transitional care

This transitional care model requires care teams to share a resource binder with case studies and care path cards to document any change in the patient’s condition. It also leverages Care Management and advanced digital care planning tools that track the quality of care. The AAACN reports that this model reduces hospital admission by 17% and leads to significant Medicare savings at all care settings.

Provider and patient transitional care qualifications

According to Advanced Data Systems, qualifying for transitional Care Management — designed to last 30 days — requires delivering care from the moment discharge planning begins after acute care has been delivered. The types of providers authorized to deliver it include specialty physicians (MDs), certified nurse-midwives (CNMs), clinical nurse specialists (CNSs), nurse practitioners (NPs), and physician assistants (PAs). They must contact the patient within 48 hours of discharge, then have a face-to-face follow-up visit within either 1 or 2 weeks, depending on the case complexity.

In order to qualify for TCM and Centers for Medicare & Medicaid Services (CMS) reimbursement, clinicians must appropriately use certified electronic health records (EHR) systems. Having a certified EHR also enables care facilities to take advantage of CMS initiatives such as comprehensive Care Management (CCM), patient-centered medical home (PCMH), and comprehensive primary care plus (CPC+) to ensure continuity of care.

To get reimbursed for TCM services, care facilities must abide by these requirements:

  • Reconcile, manage, and refill prescriptions no later than the date of the face-to-face visit.
  • Assess discharge information.
  • Review diagnostic tests/treatments and schedule follow-ups.
  • Educate the patient, family member or guardian, and caregiver.
  • Establish community provider and service referrals.
  • Help schedule follow-up visits with specialists.

To participate in TCM, patients must be discharged from one of these qualifying service settings: skilled nursing facilities, inpatient acute care hospitals, partial hospitalization, hospital outpatient observation, inpatient psychiatric hospital, or long-term care hospital.

Family and caregiver transition care support

Caregivers are critical to transition care, as they can provide valuable information about the quality of transitional care and mitigate patient safety risks for adverse effects.

The National Institutes of Health (NIH) reports that older adults who have complex chronic conditions and move across various care settings are often at higher risk of suboptimal transitional care due to conflicting care plans and self-management recommendations. Inadequate Care Management can lead to increased risk of readmissions in the first 90 days after discharge, medication side effects, functional decline, adverse effects, worsening health outcomes, and decreased patient satisfaction.

The NIH found that older patients whose caregivers supported transitional care and follow-up plans were less likely to experience rehospitalizations than those without caregivers. Despite these findings, family caregivers are often excluded in discharge, handoff, and transition Care Management. Care facilities are starting to educate caregivers on the patient’s care plan and training them on medication management. Caregivers are also learning to advocate for patients and catch prescription or recommendation errors while teaching the patient about conditions and treatments in a language and at a pace they can understand and keep up with.

Transition care billing requirements

The American Society of Health System Pharmacists recommends following these billing requirements when arranging to be reimbursed for TCM services:

  • Review the patient’s discharge documents.
  • Follow up on test and treatment requirements.
  • Ensure the patient’s beneficiary, relative, or primary caregiver is educated on conditions and treatments.
  • Establish ties with local community providers and service organizations.
  • Schedule follow-up visits with service providers and specialists.
  • Attend a face-to-face visit 1 to 2 weeks after discharge, depending on the condition.
  • Provide medicine reconciliation and management documents by the date of your face-to-face visit.

Supporting transitional care fosters well-being for the patient and promotes financial incentives for the provider. Non-face-to-face requirements of TCM include supervised clinician interaction with the patient or caregiver via telephone calls, emails, or texts within 2 business days of discharge. The provider should review records, check in with specialists about follow-up needs, educate the patient or caregiver, and make referrals for community resources or follow-up visits.

Face-to-face TCM requirements include a visit with a physician or qualified non-physician practitioners within 1 or 2 weeks of discharge. Health Care Professionals who may provide and bill for TCM Services include:

  • Physician (MD)
  • Clinical Nurse Specialist (CNS)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Certified nurse-midwife (CNM)

Discover Which Transitional Care Technology Best Enables TCM

Optimal transition care requires thorough and consistent communication between care settings, with patients, and with caregivers. EMRs and EHRs are helpful for storing and sharing data, but they were not built for Care Management. Your team will find successful TCM is within reach once they’ve implemented the right health tech platform. Help them discover the one that streamlines their workflows and gives them more time for patient care — Download Our Patient-Centered Care Management Platform Guide

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