Sujata Prasad

1 year ago · 4 min. reading time · ~10 ·

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Transitioning Patients to a New Care Setting

Transitioning Patients to a New Care Setting

What is transitional care?

"Transitional care" is a term that refers to services that are designed to ensure continuity of care for patients while they transition between care settings. For older adults who have multiple chronic conditions or complex multi-specialty plans, high-quality transitional services are crucial. They require continuity of care while they move between care settings.

According to the National Institutes of Health, poor "handoffs” of older adults and caregivers from home to hospital have been associated with adverse events, low satisfaction and high rehospitalizations. TCM improves the quality of life for patients and reduces hospital readmissions. It can also help to reduce costs for long-term care centers and nursing homes, as well as primary care.

Caregivers who work in a rehabilitation or skilled nursing facility with vulnerable elderly patients need to plan for discharge and provide transitional care. They also need frequent follow-up visits from family members to avoid hospital readmission.

What is the importance of transitional care?

The Affordable Care Act created transitional care programs in order to improve quality and lower costs at long-term care facilities, nursing homes, inpatient clinics and emergency departments. These programs have been proven to be beneficial for skilled nursing facility and rehabilitation facility caregivers. They also help patients discharged from hospital with better continuity and safer transfers between care settings.

The Health Affairs journal reviewed randomized clinical trials of transitional care interventions, care coordination upgrades and nurse team leaders. These studies showed that TCM can reduce readmissions by at least 30 days following discharge planning.

Improved Care Management is an important focus of health reform. TCM ensures that patients get the care they require from the moment discharge planning begins at a hospital or other health facility. It continues for at most 30 days to allow the patient to adjust to the new environment and avoid adverse effects.

Transitional care models

The American Academy of Ambulatory Care Nursing has standardized the Four Pillars of Care Transition Injuries -- medication, follow-up visits and red flags -- to be used in the following models of transition care:

Transitional care from hospital to home

Transitional care from hospital to home requires that the patient be prepared for discharge planning. This includes providing written instructions and technical assistance. All discharge plans must be in line with national guidelines. It is important to teach patients about risk-specific interventions and create an emergency plan, especially for patients suffering from chronic conditions such as heart failure.

Every care team responsible for transitional care and managing discharge planning must provide education and diagnosis (including diet and medication) to each patient and their caregivers. Each care team should schedule post-discharge tests and appointments before each handoff and contact each patient within 2 to 3 days of their hospital discharge. The AAACN states that this model has reduced re-hospitalizations as well as costs per patient. It also increases revenue for primary care clinics and emergency department facilities, nursing homes, and other care settings that provide transitional care.

Transitional care from the clinic to your home

Clinic-to-home care is a system that allows patients to manage their own health with the support of communities and their health care systems. This includes shared decision-making and clear clinical information. This model also uses the Assessment of Chronic Illness Care and Patient Assessment of Care For Chronic Conditions (PACIC), both of which have been proven to improve the well-being of patients suffering from asthma, diabetes, cancer, comorbid depression and bipolar disorder.

Nursing-home-to-hospital transitional care

Care teams must share a resource binder that includes case studies and care pathway cards. This is necessary to document any changes in the patient's health. The model also uses Care Management and advanced digital planning tools to track the quality of care. AAACN reports that the model results in a 17% reduction in hospital admissions and significant Medicare savings across all care settings.

Qualified providers and patients for transitional care

Advanced Data Systems states that to qualify for transitional care management, which is designed to last 30 consecutive days, you must deliver care starting from the time discharge planning starts after acute care has been provided. It is available to specialty physicians (MDs), nurse-midwives, nurse specialists (CNSs), nurse practitioners and physician assistants. The provider must contact the patient within 48-hours of discharge. They then need to have a follow-up visit in person within 1 or 2 weeks depending on the complexity of the case.

To be eligible for reimbursement from TCM and the Centers for Medicare & Medicaid Services, (CMS), clinicians must use certified electronic health records systems (EHR). A certified EHR allows care facilities to benefit from CMS initiatives like comprehensive Care Management (CCM), patient centered medical home (PCMH) and comprehensive primary care plus (+CPC+), which ensure continuity of care.

Care facilities must follow these guidelines in order to be reimbursed for TCM-related services

Conciliate, manage and refill prescriptions by the date of the face to face visit.

Assess discharge information.

Examine diagnostic tests and treatments, and plan follow-ups.

Educate the patient, guardian or family member, as well as caregiver.

Refer to community service providers and providers.

Schedule follow-up appointments with specialists.

Patients must be discharged from one or more of the following qualifying settings in order to participate in TCM: skilled nursing facilities; inpatient acute care hospitals; partial hospitalization; hospital outpatient observation; inpatient psychiatric institution; long-term care hospital.

Support for caregivers and family members in transition

Caregivers are crucial to transition care as they can provide valuable feedback about the quality and safety of care and help patients avoid adverse effects.

According to the National Institutes of Health, older adults with complex chronic conditions who move between care settings often face higher risks of receiving suboptimal transitional care. This is due to conflicts in care plans and self management recommendations. Inadequate care management can increase the risk of readmissions within the first 90 days following discharge. It can also lead to medication side effects, functional decline, worsening health outcomes, and lower patient satisfaction.

According to the NIH, older patients whose caregivers provided support for transitional care and follow up plans were less likely than those who did not have caregivers to be admitted. Family caregivers are often overlooked in transition Care Management, discharge and handoff. Caregivers are being trained in medication management and education by care facilities. They are learning to advocate for patients, catch prescription errors and teach the patient about treatments and conditions in a language they understand.

Transition care billing requirements

These are the billing requirements that the American Society of Health System Pharmacists recommends when you want to get reimbursed for TCM services.

Examine the discharge papers of the patient.

Follow-up on testing and treatment.

Make sure the beneficiary, primary caregiver, or relative of the patient is informed about conditions and treatment.

Establish relationships with community service providers and organizations.

Make sure to schedule follow-up appointments with specialists and service providers.

You should attend a face-to–face visit within one to two weeks of discharge depending on your condition.

You must provide medicine reconciliation and management documentation by the date of your face to face visit.

Transitional care supports well-being of the patient and provides financial incentives to the provider. TCM does not require that the clinician be present face-to-face with the patient or caregiver. Instead, supervised interaction should take place via phone calls, emails or text messages within two business days. The provider should review the records and consult with specialists to discuss follow-up issues.

Face-to-face TCM services require a visit with a doctor or non-physician practitioner within one to two weeks of discharge. TCM Services may be provided and billed by the following health care professionals:

Physician (MD)

Clinical Nurse Specialist (CNS).

Nurse Practitioner (NP)

Physician Assistant (PA)

Certified nurse-midwife (CNM)

To learn more, please visit Sujata Prasad New Jersey website

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