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Navigating the transition from hospital to home can be one of the most vulnerable periods in a patient’s healthcare journey. Without proper support, patients are at risk of complications, miscommunication, and even preventable readmissions. These challenges not only impact patient outcomes but also place a significant financial strain on the healthcare system.
Transitional Care Management (TCM) is a program aimed at providing smooth transitions for patients as they move from the hospital or emergency department to their home or other care settings. By ensuring timely follow-ups with primary care providers and maintaining regular communication with care coordinators, TCM keeps patients engaged and on track in their recovery. This proactive approach improves satisfaction while reducing complications, readmissions, and overall healthcare costs.
Around 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, leading to an annual cost of approximately $17 billion.
JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE (JABFM)
What Is Transitional Care Management (TCM)?
TCM is a program designed to ensure a seamless transition for patients moving from the hospital or emergency room to home or other care settings. The goal is to provide continuous support throughout this critical period, minimizing the risk of complications and readmissions.
At Netrin Health, TCM ensures seamless post-hospital care through proactive follow-ups. Care coordinators contact patients the day after discharge and schedule follow-up appointments with their primary care physician within 7 to 14 days. This approach improves health outcomes, reduces costs by preventing readmissions, and enhances patient satisfaction by fostering clear communication and trust.
Key Components of TCM in Value-Based Care
1. Patient Assessment: Care coordinators perform thorough assessments, considering the patient’s medical history, social factors, and support systems. This detailed information allows us to create personalized care plans that address each patient’s unique needs.
2. Planning and Coordination: Care coordinators actively involve patients and their families in the care planning process. This ensures that the right resources, from specialist referrals to therapy options, are available to meet the patient’s goals and preferences.
3. Health and Medication Education: Care coordinators provide vital education on the patient’s condition and treatment options. We also help patients manage their medications, promoting adherence to prevent complications.
4. Patient Monitoring: Through regular follow-ups, care coordinators monitor progress and adjust care plans as needed. This proactive approach is key to reducing readmissions and improving patient outcomes.
Impact of TCM on Healthcare Costs and Outcomes
Hospital readmissions can place a significant financial and emotional burden on patients and their families. TCM alleviates this by providing essential post-discharge support, ensuring patients have the tools to manage their health at home. This not only reduces the likelihood of readmissions but also lowers overall healthcare costs by preventing unnecessary emergency visits.
TCM services significantly decreased mortality and hospital readmissions at 18 months by 7% and 21%, respectively, compared to patients who did not receive TCM services.
JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE (JABFM)
TCM Strategy at Netrin Health
Netrin Health’s care coordinators are crucial to the success of TCM. After hospital or emergency department discharges, our team of care coordinators quickly contact patients to assess their needs, schedule primary care appointments, create personalized care plans, and track progress. They follow up diligently if a patient misses a call, ensuring continuity of care.
This personalized approach helps patients manage their conditions confidently, reduces unnecessary hospital visits, and enhances communication between patients and providers. Netrin’s TCM program ultimately improves care quality, reduces anxiety, and boosts patient confidence.
Value-Based Care and TCM: A Cost-Effective Solution
TCM supports value-based care by prioritizing preventive, proactive healthcare, reducing costs, and improving outcomes. Covered by Medicare Part B (with standard deductibles and coinsurance), TCM offers an affordable solution for post-hospital patients. Netrin Health integrates TCM to enhance patient support, reduce emergency service burdens, and contribute to a more sustainable healthcare system.
In summary, TCM reduces hospital readmissions, fosters better patient engagement, and offers cost-effective care. With personalized plans, ongoing education, and regular monitoring, TCM strengthens outcomes and builds stronger patient-provider relationships.
Contact us to learn how Netrin Health can support your patients’ recovery journey today.
References
Burdick T, Moran D., Oliver B., Eilertsen A., Raymond J., Hort S. and J. Bartels S. (2022). Transitional Care Management Quality Improvement Methods That Reduced Readmissions in a Rural, Primary Care System. Health Affairs, JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE (JABFM).