What are TCM Services?
TCM services refer to the coordination of care and management of a patient’s healthcare needs as they transition between different levels of care, such as from the hospital to home or from a nursing facility to home. The goal of TCM services is to provide continuous care by facilitating communication between the patient’s various healthcare providers and settings to help reduce medical errors, prevent unnecessary readmissions, and improve health outcomes.
Coordinating Care Across Healthcare Settings
One of the primary roles of Transitional Care Management Services is coordinating care across different healthcare settings. When a patient leaves the hospital or another institutional care setting, it is critical that timely follow-up care is provided in order to continue treatment plans and address any new or ongoing medical issues. Through TCM services, a designated transitional care manager works to ensure effective communication between all members of the patient’s care team. This includes communicating relevant clinical information from the discharging facility to the receiving providers, physician offices, home health agencies, or other outpatient facilities the patient may require treatment from. The transitional care manager also schedules necessary follow-up appointments and makes sure the patient has a plan in place to obtain any new or ongoing medications, durable medical equipment, home health services, or other post-discharge care needs.
Managing Medications and Treatment Plans
Another key responsibility of transitional care managers is managing patient medications and treatment plans post-discharge. The transitional care manager reviews the patient’s complete medication list from the discharging facility and reconciles it with the outpatient medication list. This reconciliation process is critical for catching any problems like discrepancies, duplications, interactions, or non-formulary items that may negatively impact the patient’s recovery and safety. The manager also ensures the patient understands the purpose and proper administration of each medication to prevent misuse. Treatment plans are also reviewed and follow-up appointments with specialists are coordinated as needed to continue care for ongoing medical issues per a physician’s discharge orders.
Solving Post-Discharge Issues and Providing Education
Transitional care managers play an important role in addressing issues that arise post-discharge and preventing avoidable readmissions. Through telephone communication and home visits, transitional care managers are available to solve problems patients experience like difficulty obtaining medications or equipment, scheduling transportation to appointments, understanding discharge instructions, managing new or worsening symptoms, and more. Managers provide patient education on their diagnoses, self-care needs, when to seek medical attention, identifying warning signs, making healthy lifestyle changes, and adhering to the treatment plan. They also make referrals to community resources and help patients access services like home health, durable medical equipment, or Meals on Wheels if needed. By promptly addressing issues as they come up, transitional care managers can help patients successfully transition home and avert trips back to the emergency room or readmission to the hospital.
Improving Outcomes through Coordinated Care
A growing body of evidence shows that transitional care management services can lead to improved outcomes for patients. Studies have found TCM reduces preventable hospital readmissions by 20-50% by bridging care between settings and addressing issues early on before they escalate into medical crises requiring hospitalization. Other benefits seen include improved medication adherence, fewer emergency department visits, increased patient satisfaction, and lower overall healthcare costs. By facilitating communication among the full care team from discharge through the first 30 days post-discharge, transitional care managers help provide seamless, coordinated care for patients. Their focus on discharge planning, medication management, problem-solving, and patient education improves patients’ ability to self-manage their care and make healthy adjustments as they transition home from institutional care.
The Role of Technology in Transitional Care
Technology solutions are playing an increasing role in supporting transitional care management services and facilitating communication between providers and patients. Secure messaging portals allow for exchange of information like discharge summaries, follow-up appointments, and medication lists between facilities and outpatient providers electronically in a timely, HIPAA-compliant manner. Patient engagement portals give patients direct access to portions of their medical record, test results, the ability to schedule appointments online, and messaging capabilities to reach their transitional care manager with any questions. Telehealth services provide a way for transitional care managers to conduct video or phone visits with patients to assess how they’re doing post-discharge and address problems virtually without an in-person visit if needed. Remote monitoring tools as well allow home care providers to keep tabs on patients’ vital signs, medications, activities of daily living, and reach out if issues arise electronically instead of waiting for problems to escalate to an emergency. With the adoption of technologies that support it, transitional care can be delivered more efficiently and enable patients to receive coordinated care securely from the comfort of their own homes.
Future of TCM Service
As the healthcare system continues shifting towards a value-based model focused on outcomes rather than fee-for-service volume, TCM services will play an even greater role. Their role in reducing readmissions and healthcare costs makes them attractive for alternative payment models wherein providers assume greater financial risk but also see a return on their investment in care coordination efforts that keep patients well. As baby boomers age, there will also be an increased need for transitional care programs that help high-risk, chronically ill older adults successfully transition between care levels to avoid unnecessary hospital use. Continued growth in remote monitoring technologies and home-based services will also allow transitional care to be provided with fewer in-person visits, expanding access and controlling costs. With growing evidence of their benefits, TCM service programs will likely become a integral part of healthcare systems’ efforts to provide more continuous, coordinated care for patients across settings in the future.
TCM services provide critical coordination of caare for patients transferring between healthcare levels. By facilitating communication among providers, reconciling medications, solving post-discharge issues, and educating patients, transitional care managers help ensure seamless care transitions. Their role in improving outcomes like readmission rates and patient satisfaction makes them a valuable healthcare model. Continued adoption of technologies that support remote monitoring and sharing of clinical information will help transitional care programs maximize their potential to both improve quality of care and control rising costs across the system in the years ahead.
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1. Source: Coherent Market Insights, Public sources, Desk research
2. We have leveraged AI tools to mine information and compile it.