How to Implement Successful Transitional Care Management

Every year, hospitals across the US discharge 35 million patients. For many of these people, discharge signals the end of their medical care—but it shouldn’t. 

In fact, most (if not all) patients should be engaging in some type of follow-up care after a stint in the hospital. However, one in three adults does not visit a healthcare provider within the recommended 30 days. 

Why Is Post-Discharge Care So Important? 

It’s often hard to convince people—especially those who are otherwise healthy—to follow up with their primary care provider after a hospital discharge. But there are important reasons to do so: 

• Continuity of Care: A follow-up appointment allows the provider to update the patient’s medical records. Additionally, post-discharge care often requires follow-up tests/labs or a plan of action to address abnormal results. 
• Medication Reconciliation: Hospitals often adjust medication dosages or prescribe new drugs. As a result, up to 23% of patients suffer an adverse drug event after discharge.  

Post-discharge care is even more critical for older patients or those who have pre-existing health conditions. Comorbidities increase risk for complications that lead to hospital readmission, which is costly in more ways than one. First of all, the financial impact is astronomical—an estimated $26 billion annually. Even worse, many patients pay the ultimate price. Research shows the risk of death doubles in people readmitted to the hospital within 30 days compared to those who stay out. 

Improved Outcomes, Lower Costs 

Stats like these underscore the importance of transitional care management (TCM)—comprehensive care provided to patients while they transition from one care setting, such as a hospital, to another care setting or home.  

Yet TCM is woefully underused after most hospital discharges. Where it has gained traction, though, is among Medicare beneficiaries who are part of a value-based system, which aims to improve outcomes while reducing costs.  

Transitional care management can result in a very significant 86.6% decrease in readmission rates. Medication reconciliation alone has been shown to reduce 30-day readmissions by 27%. 

Six Key Components of Successful Transitional Care Management 

According to Kim Raineri, Divisional Vice President of Clinical Operations at Innovista Health, there are six key components to successful transitional care management: 

1. Real-Time Information: Timeliness is crucial. Have a process in place to communicate discharges to the care team in real-time. Technology such as admit, discharge, and transfer (ADT) alerts can notify providers or case managers of hospital discharges so they can initiate TCM. 
2. Quick Outreach: Contact the patient or caregiver within 24-48 hours of hospital discharge. Make sure to review hospital discharge instructions and medications, assist with scheduling follow-up visits, reinforce condition-specific education, and assess for barriers related to social determinants of health that could impact ability to adhere to the recommended treatment plan. 
3. Timely Follow-Ups: Ensure the patient is scheduled for a follow-up provider visit within 7-14 days. For patients with mobility or transportation issues, consider telehealth appointments.   
4. Coordination & Communication: To ensure a smooth transition and no gaps in care, all members of the care team (specialists and ancillary providers) need to be kept in the loop about the patient’s updated health status.  
5. 30-Day Monitoring: Monitor the patient throughout the 30-day TCM process. “This may include regularly scheduled touchpoints with high-risk members to ensure that they are adhering to the treatment plan and not experiencing any complications,” says Raineri. 
6. Post-TCM Evaluation: Especially for high-risk patients, care should not end on day 30. Upon completion of the TCM program, evaluate the patient to deem eligibility for enrollment in longer-term care management programs (complex, disease-specific, or medication adherence, for example). 

Partnerships Break Down Barriers & Accelerate Adoption 

Despite the clear benefits, medical practices face several challenges when it comes to providing timely transitional care management. 

Unfortunately, hospitals don’t typically hand off patients to their personal physicians for continued care. At the same time, providers are stretched thin and don’t often have the bandwidth to check for hospital discharges or initiate timely transitional care. 

This is where partnerships with value-based managed service organizations like Innovista Health can break down barriers and accelerate the adoption and utilization of TCM. 

Innovista’s strength lies in its robust care management program, which includes comprehensive TCM that starts within 24-48 hours of hospital discharge. 

“Another way we achieve high success through our transitional care management program is by embedding a case manager in one of our highest volume acute care facilities,” Raineri adds. “Bedside assessments are conducted to identify the patient’s needs, barriers, and most appropriate discharge plan. If needed, the case manager will facilitate referrals to ancillary support services such as palliative care, home health, or durable medical equipment.” 

It’s estimated that the embedded case management program has prevented upwards of 100 readmissions over the past two years, contributing to significant cost savings for the organization. 

For more complex cases, or for patients who have transportation or health-related barriers that prevent them from leaving home, some of Innovista’s accountable care organizations have partnered with home-based providers that will conduct the TCM visit in the patient’s house. 

Widespread Benefits

Everyone benefits from transitional care management. Providers not only enhance quality of care, they lower medical costs and improve their bottom line. Patients experience better outcomes by getting the care they need to fully heal post-discharge.

Innovista Health is committed to helping providers realize the potential of transitional care management and properly implement it in their practices.