Transitional Care Management: Practical Processes for Your Practice

 

Helping patients safely bridge the gap from acute care to ambulatory care is good for patients and practices too.

Fam Pract Manag. 2019 May-June;26(3):27-30.

Author disclosures: no relevant financial affiliations disclosed.

Transitional care management (TCM) addresses the safe handoff of a patient from one setting of care to another. Most often this handoff involves a patient moving from an acute, inpatient setting to an outpatient care environment.1 Patients with chronic conditions, organ system failure, or frailty are at greatest risk during this period. Common causes of patient readmission include communication failures, procedural errors, and unimplemented care plans.2

During transitions of care, primary care physicians (PCPs) often encounter care gaps that are beyond their control due to factors such as inaccessible patient records, unclear discharge care plans, or limited effort by others to engage the primary care team or the patient and his or her caregivers.

Well-defined protocols can promote coordinated care and safe transitions, but they take time and effort to implement. Recognizing this, the Centers for Medicare & Medicaid Services in 2013 began offering payment to ambulatory care practices for TCM services, which includes contacting patients within 48 hours of their discharge, scheduling an office visit to occur within 7 to 14 days, and discussing the care plan with the patient or caregivers. (See “Transitional care management code requirements.”)

This article describes the process improvements that our practice used to enhance TCM, which led to reduced patient readmissions, improved patient and family experiences, and increased reimbursement.

KEY POINTS

  • Transitional care management (TCM) seeks to ensure that patient care doesn't suffer when the patient transfers from one care setting to another, such as from hospital to home.

  • Improving transitional care management involves improving communication between the patient or caregivers, the primary care practice, and the practice's acute/post-acute facility partners.

  • Effective, efficient TCM depends on a detailed protocol that instructs physicians and staff how to identify patients needing TCM services, schedule them for appointments within 14 days of discharge, and make sure their medication and other needs are covered.

TRANSITIONAL CARE MANAGEMENT CODE REQUIREMENTS

The CPT codes for transitional care management require one face-to-face visit, certain non-face-to-face services, and medication reconciliation and management during the 30-day service period.

Code 99495 has the following requirements:

  • Communication (direct contact, telephone, or electronic) with the patient or caregiver within two business days of discharge,

  • Medical decision making of at least moderate complexity during the service period,

  • A face-to-face visit within 14 days of discharge.

Code 99496 has the following requirements:

  • Communication (direct contact, telephone, or electronic) with the patient or caregiver within two business days of discharge,

  • Medical decision making of high complexity during the service period,

  • A face-to-face visit within seven days of discharge.

WHAT LED US TO IMPROVE TCM?

Jump to section +

ABOUT THE AUTHORS

show all author info

Dr. Patel leads the Division of Geriatrics and Palliative Care in the Department of Family and Community Medicine, Long School of Medicine, University of Texas Health Science Center in San Antonio (UT Health San Antonio)....

Ruby Mathew is an acute care nurse practitioner at UT Health San Antonio.

Dr. Aniemeke is a clinical assistant professor at UT Health San Antonio.

Dr. Tripathy is a clinical associate professor and medical director of the primary care clinic at UT Health Medical Arts & Research Center.

Dr. Jaén was interim director of the UT Health San Antonio Primary Care Center and is chair of the Department of Family and Community Medicine, Long School of Medicine.

Dr. Tysinger is a professor and vice-chair for professional development at UT Health San Antonio.

Author disclosures: no relevant financial affiliations disclosed.

References

1. Bloink J, Adler KG. Transitional care management services: new codes, new requirements. Fam Pract Manag. 2013;20(3):12–17.

2. Marder K. Transitional care management: five steps to fewer readmissions, improved quality, and lower cost. HealthCatalyst website. Oct. 17, 2017. https://www.healthcatalyst.com/transitional-care-management-reduces-readmissions. Accessed March 19, 2019.

 
 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

FPM E-Newsletter

Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights."

Sign Up Now