What are Transitional Care Management Services?
Transitional care management (TCM) services are a relatively new Medicare benefit designed to help high-risk patients transition between care settings, such as from a hospital to home or from a rehabilitation facility to home. TCM services aim to promote continuity of care by facilitating communication between providers and ensuring patients understand their conditions, care plans and medication regimens after discharge. Let's take a closer look at how these services work.

Eligibility and Identification of High-Risk Patients
Medicare covers Transitional Care Management Services for patients who meet certain criteria indicating their risk for post-discharge complications. Eligible patients must have had an acute hospital stay of at least three days or be directly admitted with same-day discharge from skilled nursing facilities (SNFs) or nursing homes. Patients are considered at high risk if they have multiple chronic conditions, a history of frequent hospitalizations or emergency room visits, a limited ability to care for themselves or social support issues impacting their care. Eligible providers work to proactively identify these high-risk patients during hospitalizations or facility stays to set them up with TCM services.

Care Coordination and Communication
Once a patient is deemed eligible, their primary care physician or other qualified health professional takes the lead on coordinating care. Within two business days of discharge, a comprehensive TCM visit must take place either face-to-face at a location convenient for the patient or via telehealth. During this visit, the provider thoroughly reviews the patient's discharge plans, treatments, medications and any follow-up needs. They will also address potential barriers to care, arrange referrals or services and make sure the patient understands what to do if any issues arise. Crucially, the provider communicates patients' status and ongoing needs with other practitioners involved in their care. Research shows enhanced provider communication reduces hospital readmissions.

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