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Transitional Care Management
Guiding patients smoothly from hospital to home.
At ClearPath Health Partners, we provide Transitional Care Management (TCM) services to help you provide positive patient outcomes and increase revenue.
What is Transitional Care Management?
Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care. It’s a vital service that aims to eliminate gaps in patient care and readmission during critical periods
TCM includes discharge from any of the following:
- Inpatient acute care hospital
- Long-term acute care hospital
- Skilled nursing facility/nursing facility
- Inpatient rehabilitation facility
- Hospital observation status or partial hospitalization
Benefits of TCM
- TCM office visits are reimbursed at twice the rate of regular office visits
- Strengthen patient relationships as they transition between care settings
- Proactively alert care management staff when enrolled patients change care settings
- Ensure patients get the help they need during care transitions
Who can Bill TCM Services?
Health Care Professionals:
- Physician (any specialty)
- Clinical nurse specialist (CNS)
- Nurse practitioner (NP)
- Physician assistant (PA)
- Certified nurse midwife
Proven Impact of TCM:
1. Reduced Hospital Readmissions
- Studies show that effective TCM programs can reduce hospital readmission rates by 20% to 50%, particularly for high-risk patients with chronic illnesses (e.g., heart failure, COPD).
2. Improved Patient Outcomes
- Patients experience better symptom management, medication adherence, and understanding of their care plans.
- TCM has been linked to improved functional status and fewer emergency department visits.
3. Cost Savings
- By avoiding preventable readmissions and complications, TCM reduces unnecessary healthcare costs.
- CMS and private insurers have reported millions in savings through TCM interventions.
4. Higher Patient Satisfaction
- Patients appreciate coordinated, continuous care, especially during vulnerable post-discharge periods.
- Surveys show TCM leads to higher satisfaction scores and better patient trust in the healthcare system.
5. Enhanced Care Coordination
- TCM promotes better communication between hospitals, primary care providers, specialists, and patients.
- This results in more accurate and timely follow-up care, closing gaps that often lead to complications.