NavCareNet.com Blog

How Transitional Care Reduces Readmissions

Posted by Dr. Joseph F. West on Dec 15, 2016 3:26:08 PM
Health systems are challenged with reevaluating transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients. Care transitions entail moving patients between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness. The settings involved in care transitions include hospitals, nursing facilities, the patient’s home, rehabilitation facilities, home health agencies, primary and specialty care offices, community health centers, community-based settings, hospice, long-term care facilities, and others. Better care transitions have the potential to reduce readmissions—the “back and forth” movement of a patient between these settings and the instability, anxiety, and risks to health this may cause.

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
The coordination of care across the health care continuum is important to the implementation, management, and evaluation of a patient’s treatment plan. TCM care teams work alongside health systems and providers to facilitate transfer and receipt of patient records between different levels of care and locations to ensure continuity. Care Managers working with electronic health records (EHRs) and other technologies can lower the potential for communication breakdowns in these processes. Collaborations between healthcare providers and TCM care managers strengthen the handoff of care plans and patient history promoting more successful treatments.

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.
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Topics: Transitional Care Management, TCM, Readmissions, Post-Acute Care, Discharge Planning

Ensuring Quality in Transitional Care

Posted by Dr. Joseph F. West on Nov 14, 2016 9:00:00 AM

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely movement of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex care needs. Any gaps in care that exist for patients and their caregivers during critical transitions can lead to adverse events, unmet needs, low satisfaction with care, and high hospital readmission rates. Improving the quality of care for chronically ill older adults during critical transitions is important for lowered healthcare costs and improved health outcomes.

Nearly 13 percent of Medicare beneficiaries discharged from hospitals experience three or more provider transfers during a thirty-day period. Approximately 20 percent of Medicare beneficiaries discharged from hospitals were readmitted to a hospital within thirty days and more than 30 percent are readmitted within ninety days. It is during these transitions that mistakes commonly occur giving rise to adverse clinical events. For example, a patient transitioning from a hospital to a nursing home or other facility may not have their medication and treatment plan communicated clearly. There may be discrepancies in the prescriptions, medical supplies or care instructions for home health as another example.

The hallmarks of transitional care are the focus on highly vulnerable, chronically ill patients throughout critical transitions. Emphasis on timely services and patient and caregiver education can help avoid poor outcomes in transitioning care. Chronic Care Management (CCM) and Transitional Care Management (TCM) can be important to during these handoffs,” or vulnerable exchange points that contribute to unnecessarily high rates of health services use.

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Topics: Transitional Care Management, TCM, Care Coordination, CCM, Care Continuity

Transitional Care: A Team Approach for Better Care

Posted by Dr. Joseph F. West on Jun 21, 2016 3:30:00 PM

Moving a patient from a hospital to their home or care facility in a community setting is a delicate process. Patients, family members or caregivers can receive confusing recommendations, a laundry list of medications, and conflicting instructions regarding follow-up care. If they are not included in planning or provided with clear “next steps” there can be significant gaps in post-discharge care. As a result, patients will most likely return to the hospital, and often times with more complications than before.

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Topics: Chronic Care Management, Transitional Care Management, Population Health Management, Senior Health

Catching Your Breath Through Transitional Care

Posted by Dr. Joseph F. West on May 24, 2016 1:30:00 PM

When someone can’t breathe nothing else matters. Enjoying the simplest pleasures of daily life become a struggle. Patients with complex health conditions and seniors with serious breathing problems take in less oxygen and therefore have less energy for daily tasks. This can dramatically reduce one's quality of life. As a result, patients can often feel anxious, fatigued, and depressed. The help of caregivers becomes increasingly important as breathing difficulties persist.

Chronic obstructive pulmonary disease (COPD) (i.e. emphysema or chronic bronchitis), and asthma are two chronic breathing conditions that burden seniors and patients with complex conditions the most. Damaged air sacks (alveoli), obstructed airways, or chronically inflamed lungs can block breathing and increase risks for developing infections. These patients are highly sensitive to irritants and require more assistance in reducing and preventing exposure to triggers that exacerbate symptoms.

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Topics: COPD, Transitional Care Management, Breathing

Getting the Most from Chronic Care Management

Posted by Dr. Joseph F. West on May 17, 2016 2:28:20 PM

Nearly 1 out of 3 people in the U.S. population has at least one chronic disease, such as chronic obstructive pulmonary disease (COPD), diabetes, heart disease or hypertension. Costs in general for managing chronic diseases can be overwhelming as 86 cents of every healthcare dollar goes to treatment of chronic diseases.^ For most providers, managing chronic diseases and patients with compounding medical and psychosocial needs can be overwhelming.

Practices and clinicians recognize the challenges of coordinating care for these complex conditions, as well as the importance of staying connected to their patients for better quality of care.

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Topics: Chronic Care Management, Transitional Care Management, Population Health Management


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This blog allows us the opportunity to share insights into unique information, news and updates, as well as provide a place to interact with you. As a care management organization, our blogs will take you through the many facets of care management, from chronic care and transitional care management, to population health management which is where we begin.

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