Transitional Care Management (Tcm) Can Help Improve Patient Outcomes

Patients go through a very significant moment when they leave the hospital or a skilled nursing facility and return to their home or neighborhood. Patients who don't get the right help are more likely to have issues and return to the hospital. Transitional Care Management (TCM) aims to bridge this gap by ensuring care coordination for 30 days following discharge.





What does it mean to manage transitional care?

The purpose of TCM services is to make sure that the move from inpatient to outpatient care goes smoothly and safely. These services are especially useful for those with many health issues, multiple comorbidities, or significant health changes while hospitalized.

The main goals of TCM are:

  • Reduce the risk of needing to go back to the hospital.

  • Make patients feel better.

  • Improve health outcomes.

  • Make it easy for doctors and nurses to work together.


Key Parts of TCM Services

There are some key things that make TCM operate well:

Talking to the Patient and Caregiver: You should call the patient or their caregiver within two business days of their discharge to go over the transition plan and any additional worries they may have.

Medication Reconciliation and Management: Checking the patient's meds and making sure they are taking them as directed to avoid mishaps.

Face-to-Face Visit: Scheduling an appointment with the patient to see them in person within a particular amount of time to check on their health and make any adjustments to their care plan that are needed.

Care Coordination: Making sure the patient receives the services, referrals, and follow-up appointments they need to perform better and stay healthy.

Patient education means giving the patient and their family information about the patient's sickness, treatment plan, and how to take care of themselves.

How much TCM services cost

To ensure they are paid correctly for TCM services, healthcare professionals must follow certain billing codes and rules:

CPT Code 99495: For making medical choices that aren't too hard. The patient needs to visit a healthcare professional in person within 14 days after being discharged.

CPT Code 99496 is used to help doctors make really challenging medical decisions. Patients must be seen in person within seven days of being discharged.

You should keep in mind that you can only bill one TCM code for each patient every 30 days. The face-to-face visit is also part of the TCM service and should not be charged separately. It is crucial for providers to thoroughly document all necessary TCM components to back up the chosen billing code.

Benefits of Using TCM

A systematic TCM program has many benefits, such as

Better Patient Outcomes: By maintaining a close check on patients after they leave the hospital, doctors can detect and resolve problems early, which leads to better health outcomes.

Lower Rates of Readmission: Positive TCM makes sure that patients receive the necessary follow-up care and support so they don't have to go back to the hospital.

Better Patient Satisfaction: Patients are happy because they get more individualized attention and assistance as they make the switch.

Financial incentives: TCM services can be more profitable if they use value-based care models and have reduced penalties for readmissions.

Last Thoughts

Transitional Care Management is an important feature of patient-centered care that makes sure that people can go home from the hospital without any complications. By following the guidelines and billing codes that are already in place, healthcare practitioners may give patients all the help they need during this vital time. This will make patients happier and lead to greater results.

Ready to streamline your TCM program and improve patient transitions? Explore HealthArc’s TCM solutions today and see how seamless care coordination can enhance both outcomes and operational efficiency. Schedule Demo Now

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