The Transition of Care Visit and Why We Should Care
Transitional Care Management Services (TCMS) refers to coordinating and managing a patient’s care as they transition out of an inpatient setting. These transitions and the subsequent management could be from planned or unplanned admissions. Did the patient go in for a knee replacement and it was completely planned or is the patient a diabetic, hasn’t seen their provider in a while and isn’t on the correct medication, or isn’t taking medication at all, and goes into diabetic ketoacidosis? The latter sounds more life threatening, but studies have shown that all-cause readmissions within 30 days are associated with over $40 billion in hospital costs. It’s no wonder the TCMS visit has consistently been a measure in value-based care models. In the outpatient setting, it’s critical to get this patient into the office so their care team has an up-to-date picture of the patient’s current health status. Performing an updated medication reconciliation and creating a care plan for the patient to follow after the hospitalization is statistically the best approach to preventing a readmission. This lowers total cost of care and improves overall quality of life for the patient.
The process of the TCMS sounds so simple. The patient is discharged from the hospital and they are told by the hospital to notify their primary care of their hospitalization. However, depending on the patient’s cognitive status at discharge or in the hustle and bustle of just wanting to get out of the hospital, the patient forgets to do this. They are then immediately at risk of readmission.
Through increased awareness, health information technology and overall better communication between the inpatient setting and primary care providers, the use of the TCMS codes that are being billed have improved. However, there can still be a lot barriers on the practice level. Who is going to take that phone call to speak with the patient within two business days following the discharge? Depending on the complexity of medical decision making required, does the practice have the availability to schedule an appointment within the 7 or 14 day period? Is the practice having a difficult time getting a copy of the discharge information?
It's important to review your processes, ensure you have everything in place to properly perform this visit, and then accurately code the visit to get credit for it. The TCMS visit is well-proven to lower cost of care and improve patient outcomes.