Journal article
Building a Financially Sustainable Transitional Care Management Workflow: Using nurses and other staff to coordinate the care of patients being discharged from hospitals allows physicians to fulfill TCM requirements at sustainable costs
Family practice management, Vol.30(1), pp.18-21
01/01/2023
PMID: 36626215
Abstract
Transitional care management (TCM) is a Medicare-billable service designed for health care teams to care for patients during their transition from hospitalization to home. The essence of TCM is that a physician or other clinician takes charge of the patient's care upon discharge to prevent care gaps. Evidence has shown that transitional care is needed to prevent adverse outcomes and improve quality of care.1–3
Our primary care clinic in an academic hospital implemented a team-based workflow to ensure we identified TCM-eligible patients and provided them appropriate care. After two years, our data has shown that the workflow not only improves patient outcomes and decreases emergency department visits but also can be financially sustainable. This article provides a roadmap for other practices to implement their own TCM workflow.
Details
- Title: Subtitle
- Building a Financially Sustainable Transitional Care Management Workflow: Using nurses and other staff to coordinate the care of patients being discharged from hospitals allows physicians to fulfill TCM requirements at sustainable costs
- Creators
- Jessica RockafellowRachael EdelenWendy Shen
- Resource Type
- Journal article
- Publication Details
- Family practice management, Vol.30(1), pp.18-21
- Publisher
- American Academy of Family Physicians
- PMID
- 36626215
- ISSN
- 1069-5648
- eISSN
- 1531-1929
- Language
- English
- Date published
- 01/01/2023
- Description audience
- Professional
- Academic Unit
- Family and Community Medicine
- Record Identifier
- 9984360035302771
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