Transition of Care (TOC) is a CMS reimbursement intended to help patients as they move from an acute setting back to the community. A smooth transition back home is essential if we are to help patients maintain their health long-term, keep more patients in their homes, and reduce unnecessary readmissions.

What is Transitional Care Management? 

Transitional Care Management (TCM) occurs whenever a patient moves from one care setting back to another. TCM is simply care management to help patients transition from one care setting to another. This can be from home to a hospital, from the hospital to a skilled nursing facility, and from the skilled nursing facility to back home. In most instances, TCM is a result of a discharge from an inpatient hospital.

In many instances of post-hospitalization or other inpatient facility stays, patients may experience new diagnoses, a medical crisis, or changes in their medication therapy. It is imperative to have transitional care management services in place to help meet the needs of the patient. 

Why is Transition of Care Important? 

The goal of transition care management is to improve the quality of life for patients and to help prevent hospital readmission.When a patient transitions from one care setting to another, gaps in care can result from ineffective communication,  procedural errors, and unimplemented care plans. Well-defined TCM protocols can help promote coordinated care and safe patient transitions. 

Patients with chronic conditions, organ system failure, and the elderly are particularly at risk during transitional periods. These patients in particular can benefit from transition of care. Through coordinated efforts, TCM is shown to significantly reduce the emergency department visits and readmissionsrehospitaliations among at-risk patients. 

Not only does TCM benefit the patients, it also benefits the practice.Transitional care programs can help health care providers reduce the cost of care and increase their practice revenues. 

What is the Transition of Care Process?

The first step in a patient’s transition is discharge. At discharge, patients and their caregivers are eager to get home, and the wealth of information offered is often forgotten, misunderstood, or lost in the rush. To address this quick disconnect from the healthcare system, clinical staff will contact the patient by phone within 2 days (a requirement of the reimbursement). 

This call is an opportunity for the patient to ask questions now that they are comfortably at home and have had time to consider the next steps. Caregivers, too, can learn more about their role in the ongoing care of their loved ones.

After a patient is discharged, other components of TCM include the following:

• The coordinator schedules a follow-up face-to-face visit within 7-14 days post-discharge.  
• From the clinical side, medication reconciliation, home health, DME, labs, and community resources are essential to follow up on. 
• The patient sets up a face-to-face appointment within 7-14 days with the attending physician or their primary care physician (the second part of the reimbursement).

What Are the Challenges for Providers?

Effective transitions for patients are crucial to delivering good outcomes. With multiple stakeholders – patients, acute facilities, and follow-up practitioners, delivering effective and coordinated care during the transition is extremely difficult. 

The fact that TOC usually falls outside normal office workflows greatly magnifies the challenge. Fortunately, companies like Signallamp offer TCM solutions to boost the performance of your TCM program. Our experienced staff and tested workflows allow patients to get the good follow-up care they need and their providers to care better for their patients during this critical time.

Signallamp Transition Care Management Services 

Signallamp Health delivers a personalized approach to chronic care management. Our RNs are dedicated to your practice and collaborate with your care team to create one-on-one connections with patients outside of the office. 

Signallamp Health works seamlessly within your EMR (no integration required), provides TCM services by RNs, and does so at no cost to the practice. Signallamp Health is good for your patients and good for your practice.