What are Transitional Care Management Services?
Transitional care management (TCM) services are a relatively new Medicare benefit designed to help high-risk patients transition between care settings, such as from a hospital to home or from a rehabilitation facility to home. TCM services aim to promote continuity of care by facilitating communication between providers and ensuring patients understand their conditions, care plans and medication regimens after discharge. Let's take a closer look at how these services work.

Eligibility and Identification of High-Risk Patients
Medicare covers Transitional Care Management Services for patients who meet certain criteria indicating their risk for post-discharge complications. Eligible patients must have had an acute hospital stay of at least three days or be directly admitted with same-day discharge from skilled nursing facilities (SNFs) or nursing homes. Patients are considered at high risk if they have multiple chronic conditions, a history of frequent hospitalizations or emergency room visits, a limited ability to care for themselves or social support issues impacting their care. Eligible providers work to proactively identify these high-risk patients during hospitalizations or facility stays to set them up with TCM services.

Care Coordination for Complex, High-Risk Patients
TCM services focus especially on patients with complex medical needs, multiple comorbidities, or those at high risk for readmission or complications. For these vulnerable populations, close communication and care coordination is crucial. The TCM provider acts as the hub, keeping abreast of changes in condition or needs and facilitating smooth hand-offs between care team members. They help bridge gaps to address social or environmental barriers outside clinical needs as well. This level of oversight can help high-risk patients avoid deterioration, adverse events or unnecessary acute care visits.

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