Transitional Care Management Across the Continuum
Let's dive into the world of transitional care management (TCM) through the lens of compassion and patient-centricity. 🌟
Take a moment to reflect on your TCM operations. Think about when and where you allocate your resources to make the patient's journey through complex healthcare settings as seamless as possible. Your TCM efforts could involve providing follow-up care after a patient's discharge from an inpatient stay. On the other hand, your TCM process might be more extensive, including post-discharge support following inpatient rehab and skilled nursing facility visits.
Now, consider this: Are TCM billing regulations inadvertently restricting the scope of our TCM operations? Are they unintentionally creating boundaries between the acute care setting and primary care setting? Should we consider initiating the TCM process even before the patient's discharge? Imagine care teams collaborating in both the inpatient and ambulatory settings, alongside ACO care coordinators, to ensure a smoother transition. In the healthcare industry, we often kickstart the ambulatory TCM billing process on the day of discharge or post-discharge. TCM primarily focuses on meeting payment standards, which begin on the day of discharge. Our goal is to reach out to the patient within two business days after discharge, be it through phone calls, emails, or face-to-face interactions. But here's the thought – while hospitals might have readmission performance improvement initiatives in place, they may not always encompass a vital element of the care team: the care coordinator. These transitional care coordinators can provide a comprehensive view of the patient, addressing not only clinical concerns but also potential non-clinical barriers to health. They become key communicators, sharing the patient's holistic health journey before and after their acute care episode. Their insights become invaluable in discussions around the patient's next level of care.
The objectives, productivity, and outcomes of transitional care coordination may align with inpatient case management departments in some ways. However, they have a unique focus on cost reduction and enhancing the quality of care and the patient experience.
As ACOs continue to evolve and gain more experience, their ability to coordinate care across the full healthcare spectrum improves, ultimately resulting in reduced expenditures and readmissions. As organizations committed to ACO or population health principles, we must remember that transitional care management extends far beyond the acute-care hospital or emergency room. The trend is clear: with extended MSSP participation, we're seeing decreased expenditures not only in acute care but also in long-term care, skilled nursing facilities, and home health services.
Let's put patients at the heart of our TCM strategy, ensuring a seamless and compassionate healthcare journey throughout the continuum of care. 🌿 #PatientCenteredCare #TransitionalCareManagement #MedicareSharedSavingsProgram #CareCoordination
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