One in five Medicare beneficiaries is readmitted to the hospital within thirty days of discharge. Improved care transitions have the potential to reduce readmissions by enhancing communication and coordination among providers and minimizing the discomfort and insecurity among patients. Medicare now pays physicians and other qualified non-physician professionals for post-discharge transitional care management services under CPT codes 99495 and 99496. Transitional Care Management (TCM) care teams can help providers with:
- Medication Reconciliation Follow-up
- Visit Scheduled (as needed)
- Make or Follow-up on Referrals to Post-Acute Care, Community, and other resources
- Health Coaching & Education
- Assistance in Scheduling Face-to-Face Visit within 7 or 14 Days of Acute-Care Discharge
- Help to Arrange Transportation for Patient Face-to-Face Visit
- Post-Visit Follow-up
Successful hospital and health system initiated transitional care programs require a “bridging –strategy” that includes both pre-discharge and post-discharge interventions. Transitional Care Managers can bring together multi-component strategies that include community resources, patient engagement and education, and communication with outpatient providers. Effective care transitions can boost pay for performance and quality measures for hospitals, providers and health systems, namely lowering penalties and improving reimbursement based on readmissions rates. Strong care transitions can also elevate provider image and reputation.
Older adults with multiple chronic diseases, and often several medications and home care concerns require constant monitoring and reporting on progress and changes in their conditions. Transitional Care Managers can help eliminate confusion regarding treatment plans, duplicative testing, discrepancies in medications, and missed physician follow-up. Together, this collaboration eradicates fragmented care and boosts patient satisfaction and quality of life.