Transitional Care Management

What is TCM?

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

How it works

Required patient transitional care management (TCM) services include:

  • Supporting a patient’s transition to a community setting
  • Health care professionals who accept patients at the time of post-facility discharge, without a service gap
  • Health care professionals taking responsibility for a patient’s care
  • Moderate or high complexity medical decision making for patients with medical or psychosocial problems

The 30-day TCM period begins on a patient’s inpatient discharge date and continues for the next 29 days.

TCM services begin the day of discharge from 1 of these inpatient or partial hospitalization settings:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Inpatient rehabilitation facility
  • Long-term care hospital
  • Skilled nursing facility
  • Hospital outpatient observation or partial hospitalization
  • Partial hospitalization at a community mental health center

After inpatient discharge, the patient must return to their community setting. These could include:

  • Home
  • Domiciliary (such as a group home or boarding house)
  • Nursing facility
  • Assisted living facility

Proven benefits

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.

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.

Our approach

AYA Digital solution is designed to help service providers with care transition:

  • Efficiently manage patients to improve outcomes and reduce hospital readmissions
  • Generate new revenue streams from TCM and other care management services
  • Optimize team’s efficiency and grow business without adding overhead
  • Customize care plans and workflow to support the way to deliver care
  • Adapt as new revenue opportunities or industry requirements emerge

AYA Digital automates the entire care transition workflow:

  • Enrolling the patient
  • Creating the electronic care plan
  • Reconciling medications
  • Scheduling and documenting phone calls and other care coordination activities
  • Generating reports needed for billing purposes

According to the Centers for Medicare and Medicaid Services (CMS), “care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year”.