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What is Transition Care Management (TCM)?

Transition care management (TCM) is a form of medical care that focuses on assisting patients transition from a hospital or other healthcare facility to their home or another care setting. It is designed to improve patient outcomes, decrease hospital readmissions, and make sure that patients receive the care they need as they move from one healthcare setting to another.

Chronic medical conditions, including heart disease, COPD, dementia, diabetes, and others require a transition period between the in-patient stage and the patient settling into care at home. The same is true for major surgical procedures. Transitional care management offers consistent after-discharge care to both groups of patients to avoid a relapse or readmission.

Transitional care management is designed to last for 30 days. It starts on the date of the patient’s discharge from the hospital and continues for the next 29 days. TCM services can be provided by healthcare professionals including physicians (any specialty) and qualified, legally authorized non-physician practitioners (NPPs), such as physician assistants (PAs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and nurse practitioners (NPs). In many cases, Medicare will cover the costs connected with the patient's transitional care management. It is important for patients to confirm that the healthcare provider they have is approved by Medicare.

What Does Transition Care Management (TCM) Involve?

Transition care management usually involves 3 broad categories:

  • Interactive communications
  • Non-face-to-face service delivery
  • Face-to-face visits

Interactive communications are made within the first two days of discharge to find out the status and transitional requirements of the patient. Healthcare call centers are of crucial importance in carrying out this phase of TCM. The outcomes of the call can lead to face-to-face visits, which are carried out 7 to 14 days after discharge. Non-face-to-face service delivery fills in the intervals between in-person visits. They can be carried out through medical patient portals or phone calls.

What are the Qualification Criteria for Transition Care Management?

To qualify for transition care management, the patient should be discharged from a qualifying service setting such as an inpatient acute care hospital, skilled nursing facility, or hospital outpatient observation. The patient should also have a documented medical record that shows that the patient needs additional support from a physician, a non-physician provider, or other clinical staff. The main objective of TCM is to make sure that there are no gaps in the patient's care. As such, the TCM service provider will help with medical decision-making during the transition period. The level of medical decision-making necessary to meet the individual patient's requirement will be determined by factors such as the amount or complexity of medical records and diagnostic tests, the number of possible diagnoses or management options, and the risk of significant complications.

What are the Functions of Transition Care Management (TCM)?

Some of the tasks carried out by transition care management include:

  • Medication management and prescription assistance.
  • Obtaining and reviewing discharge information. This may include continuity of care documents or a discharge summary, for instance.
  • Connecting and interacting with health care providers to ensure continuity of care. By establishing the primary needs of a patient, appropriate healthcare services can be arranged.
  • Evaluate the need for diagnostic tests, treatments, or follow-up on results from previous appointments.
  • Assistance with scheduling necessary appointments with healthcare professionals and services. By attending appointments after discharge and receiving suitable care, patients will be less likely to be readmitted because of their condition.
  • Providing support and education for adherence to treatment regimen. This may be particularly valuable for patients, their families, guardians, and/or caregivers. Education that aligns with self-management, daily activities, and independent living with regard to the patient's condition may also be offered.
  • Contact the caregiver or patient within 2 business days following discharge. The contact may be through telephone, email, or a face-to-face visit.
  • Conduct a follow-up visit within 7 or 14 days of discharge, depending upon the complexity of medical decision-making involved.
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