Are you or a loved one in the Boca Raton area in need of transitional care management (TCM) to ensure a smooth and continuous journey towards better health? Chronic conditions often require careful monitoring and management, and the transition from inpatient care to a community setting can be a critical period. In this article, we’ll explore the significance of Transitional Care Management and how it can help you or your family member achieve a successful transition while staying healthy.

Understanding Transitional Care Management:

When it comes to chronic conditions like heart disease, dementia, COPD, diabetes, and others, managing them within a community setting is often feasible. However, the gap in care during the transition from a hospital to an in-home or community setting can put patients at risk of relapse and hospital readmission. This is where Concierge Primary Care Transitional Care Management steps in to bridge that gap.

The primary purpose of Transitional Care Management is to ensure the seamless continuation of care during this transition phase. By taking charge of a patient’s health during this crucial period and focusing on a successful transition, TCM significantly reduces the chances of readmission.

What’s Included in Transitional Care Management:

Transitional Care Management services cover a 30-day period, commencing from the patient’s hospital discharge. These services can be provided by healthcare professionals, including physicians and qualified non-physician practitioners like nurse practitioners, clinical nurse specialists, certified nurse-midwives, and physician assistants.

The services can be categorized into three main areas:

1. Interactive Contact: This involves communication through email, telephone, or face-to-face interactions. The first contact should occur within two business days following hospital discharge. The initial contact aims to address the patient’s status and transitional needs, and it may be conducted by the TCM provider or clinical staff. If the physician or another qualified professional is not directly involved, the conversation must be documented and shared with the provider to address the patient’s status and medical concerns.
2. Non-Face-to-Face Services: Over the 30-day TCM period, healthcare professionals may engage in activities such as reviewing discharge information, coordinating with other healthcare professionals to ensure continuity of care, assessing the need for treatments, scheduling required appointments, providing education and support for treatment adherence, and assisting with medication management.
3. Face-to-Face Visits: A face-to-face visit is expected to occur within 7 to 14 days of discharge.

Qualifying for Transitional Care Management:

To qualify for Transitional Care Management, a patient must be discharged from a qualifying service setting such as a skilled nursing facility, inpatient acute care hospital, partial hospitalization, hospital outpatient observation, or inpatient psychiatric hospital. The patient’s medical records should indicate their need for additional support from a physician, non-physician provider, or clinical staff.

Insurance Coverage for Transitional Care Management:

Medicare often covers the costs associated with transitional care management. Patients should ensure that their healthcare provider is approved by Medicare. The costs related to Medicare’s coverage for TCM services are outlined in Medicare Part B, including a monthly premium, a deductible, and coinsurance.

For patients with Medicare Advantage (Part C), the plan should offer the same level of coverage as the original Medicare plan (Part A and Part B), making it another option for TCM coverage. Patients should verify that their service providers are in-network, as Part C costs may differ from original Medicare.

Billing Frequency for Transitional Care Management:

TCM is a temporary arrangement, and billing should include a one-time, non-recurring fee. The health care provider submits the bill after 30 days of discharge.

The Role of Transitional Care Hospitals:

Transitional care hospitals, also known as long-term care facilities, offer extended care to patients who aren’t immediately ready to return home. Patients at these facilities receive supervised medical attention, rehabilitation services, and specialized care.

In conclusion, Concierge Primary Care Transitional Care Management plays a crucial role in ensuring a seamless transition for patients managing chronic conditions. Whether the path to recovery includes a stay at a long-term care hospital depends on individual needs and input from the patient’s physician and care team. If you or a loved one in the Boca Raton area requires TCM services for chronic condition management, consider our new patient process for a smooth and successful recovery. Your health and well-being are our top priorities.

Patients happy with the personalized transitional care management they’ve received can become members of our Direct Primary Care services that provides personalized healthcare, medication management and wellness.