What is Transition of Care?

What is Transition of Care, how does it help my patient, and what are the challenges for providers?
Transition of Care (TOC) is a CMS reimbursement intended to help patients as they move from an acute setting back to the community. The smooth transition back home is essential if we are to help patients maintain their health long term, keep more patients in their home, and reduce unnecessary readmissions.
At discharge, the first step in that transition, 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 contact the patient by phone within 2 days (a requirement of the reimbursement). The call is an opportunity for the patient to ask questions now that they are comfortably at home and have had time to consider next steps. Caregivers too can learn more about their role in the ongoing care of their loved one.
From the clinical side, medication reconciliation, home health, DME, labs and community resources are essential to follow up on. And lastly, the patient sets up a face-to-face appointment with 7-14 days with the attending physician or their primary care physician (the second part of the reimbursement).
Effective transitions for patients are crucial to delivering good outcomes. With multiple stakeholders – patient, acute facility 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. 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.

About Signallamp Health
Signallamp Health delivers a personalized approach to chronic care management. 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 care management services by RNs, and does so at no cost to the practice. Signallamp Health is good for your patients and good for your practice.
To learn more about Signallamp Health’s nurse-led care management services, connect with John Taylor at (610) 675-6887 or JohnT@signallamphealth.com. Find us online at www.signallamphealth.com.