Overview of Transitional Care Management
Transitional care management (TCM) includes services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making. TCM provides an essential pathway for patients who are high utilizers and those with the highest risk for readmission by bridging the post-hospital discharge gap with personalized clinical coordination across the care continuum. The transition of care includes a discharge from hospital settings such as an inpatient acute care hospital, an inpatient psychiatric hospital, an LTC hospital, a SNF, an inpatient rehabilitation facility, a hospital outpatient observation or partial hospitalization, and a partial hospitalization at a community mental health center.
How Telehealth Makes a TCM Program High Touch and High Tech
Telehealth and virtual care enables post-acute care organizations to engage their patients and coordinate and optimize care at every interaction during a TCM program. Synzi’s HIPAA-compliant virtual care platform helps clinicians:
- Use video to check-in with patients, share patient education, and answer questions in real-time. Multiple care team participants – and the patient’s family caregiver and a medically-certified interpreter – can be included in the virtual visits to ensure alignment on the next phase in the continuum of care.
- Deliver a cadence of ongoing messages which drive better patient understanding of one’s condition(s) and medication adherence. The messaging can be personalized to reflect the patient’s multiple conditions and translated into the patient’s primary or preferred language.
- Leverage assessments and RPM technology to monitor patients on a regular basis. Clinicians can gain insight into the patient’s progress in between visits and explore if the plan of care may need to be changed or if the patient’s change in condition necessitates a more immediate intervention.
Patients are better managed from a frequency and personalized perspective, leading to better clinical outcomes for the patient and better financial outcomes for payors, referral sources, and home health providers. These virtual interactions are even more critical amid the COVID-19 pandemic as patients (and their family caregivers) may be restricting in-person visits for fear of infection and/or transmission. With the Synzi virtual care platform, TCM organizations are able to keep patients at-home and on track with their treatment while protecting patients, staff and limited PPE supplies.
TCM and the Triple Aims of Healthcare
TCM is also gaining traction as a driver of the Triple Aim of healthcare. As Marc Price, D.O. shared with AAFP, “We noted a decrease in our hospital readmission rate, a small increase in Medicare payment, improved communications with outside organizations and greater patient satisfaction. I also found an unexpected benefit — an improvement in my staff’s job satisfaction. They felt more proactive in caring for our patients. They took ownership and pride in providing care to our patients as part of a team. Not only did they become endeared to our patients, but the patients became endeared to them, too.” Given the immediacy and impact of virtual care, it is not surprising that the combination of TCM and telehealth can drive greater staff satisfaction, retention, and engagement – thus, helping a healthcare organization achieve the Quadruple Aim.