Transitional care management (TCM) is a Medicare-billable service designed for health care teams to care for patients during their transition from hospitalization to home. The essence of TCM is that a physician or other clinician takes charge of the patient's care upon discharge to prevent care gaps. Evidence has shown that transitional care is needed to prevent adverse outcomes and improve quality of care.^1–3

Our primary care clinic in an academic hospital implemented a team-based workflow to ensure we identified TCM-eligible patients and provided them appropriate care. After two years, our data has shown that the workflow not only improves patient outcomes and decreases emergency department visits but also can be financially sustainable. This article provides a roadmap for other practices to implement their own TCM workflow.

TCM REQUIREMENTS AND CHALLENGES

Medicare beneficiaries are eligible to receive TCM services in the 30-day period following their discharge from an inpatient or partial hospitalization setting. TCM includes several components:

• An interactive contact within two business days of discharge. This can be a phone call, e-mail, or face-to-face communication with the patient or caregiver by the physician or clinical staff. The medical record must include documentation of at least two attempts to contact the patient.

• Certain non-face-to-face services. These include, but are not limited to, reviewing the hospital course and discharge summary, following up on or ordering pertinent tests, ensuring referrals are made, and educating the patient and caregiver.

• A face-to-face visit. This must be completed within 14 days of discharge and requires a minimum of moderate-complexity medical decision making for code 99495 (this is measured similarly to medical decision making in an evaluation and management visit).⁴ If the face-to-face visit occurs within seven days of discharge and the medical decision making is high-complexity, then the TCM is eligible for higher reimbursement using code 99496.

Primary care physicians face several challenges in providing effective and timely transitional care. Hospitals often function in silos and do not provide a “warm handoff” of the patient to the physician or assign responsibilities at the time of discharge (e.g., who gets notified if the patient develops problems during the transitional period). Clinicians have little time to check for discharges or initiate TCM because of their busy clinic responsibilities and consistent pressure of clinical productivity. And in the past, the payment system provided little financial incentive for collaboration during the transition between inpatient and outpatient care. Medicare introduced TCM codes in 2013 to change the incentives and promote better care coordination.