Transitional care management (TCM) is a process in which qualified health professionals provide care to individuals following hospital discharge. These services are provided by qualified non-physician practitioners, such as social workers, and by physicians. The services offered by a transitional care manager are designed to reduce preventable readmissions and medical errors, while ensuring continuity of care. In addition to these goals, TCM has been shown to improve quality of life for those involved.

In order to be eligible for TCM, patients must be discharged from a service setting that qualifies as a qualifying service. During this period, the patient must be on a psychiatric or acute care hospital. It is also important to note that the patient must need additional support. The provider will assist the patient during this transition period and ensure that there are no gaps in care. The provider will also help the patient manage medical decision-making.

The implementation of TCM requires cooperation between the inpatient provider and the acute care setting. Nursing staff should be actively involved in a TCM implementation, as well as leadership. Collaboration with coding and billing staff is also crucial in developing complete documentation and establishing systems to bill for service. TCM is a valuable complementary therapy for people with a wide range of conditions. If your facility has the resources and training, you can easily implement this method in your practice.


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