transitional care management

What is Transitional Care Management (TCM)?

Learn more about Transitional Care Management and its components.

What is Transitional Care Management (TCM)?

Transitional Care Management, abbreviated as TCM, is defined by the American Academy of Family Physicians as services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making. This care is implemented when a hospital inpatient is being transitioned back to the patient’s community setting. The period for transitional care management runs for 30 days. This period begins on the date the patient is discharged from the inpatient hospital setting.

What are the Requirements for Transitional Care Management?

The Centers for Medicare and Medicaid Services (CMS) have outlined several requirements for TCM services, which include:

  • Transitional care services are required during the patient’s transition to the community setting after certain types of discharges.
  • The provider accepts care of the patient post-discharge from the facility setting without a gap.
  • The provider is responsible for the patient’s care.
  • The patient has medical and/or psychosocial problems that require moderate or high complexity medical decision making.

Transitional Care Management can be implemented when patients are discharged from certain inpatient hospital settings. Examples of these include (but are not limited to) long term patient care hospitals, inpatient acute care hospitals, inpatient rehabilitation facilities, and inpatient psychiatric hospitals. Once a patient leaves one of these settings, they must be transitioned back to their community setting. Community settings include the patient’s home, rest home, or assisted living facility.

Who Can Provide TCM Services?

CMS has defined what kind of medical providers can render transitional care management services. Those providers are:

  • Physicians (any specialty)
  • The following non-physician practitioners (NPPs) who are legally authorized and qualified to provide services in the state which they are furnished:
    • Certified nurse-midwives (CNMs)
    • Clinical nurse specialists (CNSs)
    • Nurse practitioners (NPs)
    • Physician assistants (PAs)

The above NPPs may provide non-face-to-face TCM services.


The Components of Transitional Care Management

TCM has three main components. These must be completed during the 30 days after a patient is discharged from certain inpatient hospital settings. These components ensure that the patient’s needs are being met. In addition, being actively engaged in their care will hopefully help avoid hospital readmission.

  1. Initial Contact: Interactive contact must be made with the patient and/or the patient’s caregiver within 2 business days of the patient being discharged and transitioned to the community setting. This contact can be made by either the provider or the clinical staff. The initial contact may be a telephone call, email, or face-to-face visit or interaction.
  2. Non-Face-to-Face Services: A variety of non-face-to-face services must be furnished by the provider or NPPs. These range from items like obtaining and reviewing discharge information to establishing referrals and arranging for needed community and health resources. Other non-face-to-face services include providing education to the patient, family, guardian, or caregiver, assisting in scheduling follow-up appointments, and interacting with other healthcare professionals that are involved in the patient’s care.
  3. Face-to-Face Visit: The face-to-face visit component of transitional care management must be completed within seven or 14 days of the patient’s initial discharge. This timing depends on the medical decision complexity for a patient. TCM services that require moderate medical decision complexity must take place within 14 days of the patient’s discharge. High medical decision complexity cases require a face-to-face visit within 7 days of patient discharge.

There are two Current Procedural Terminology (CPT) codes providers must use for face-to-face visits, depending on medical decision complexity. CPT Code 99495 represents moderate medical decision complexity (billed from the 8th to 4th day); CPT Code 99496 represents high medical decision complexity (billed from 0 to 7th day). These TCM codes should be used as part of the TCM services, not reported separately.

TCM Sample Process Map and Workflow

Each practice and provider operates differently, but below is a sample used by the Garden Practice Transformation Network.

transitional care management
  1. A Patient is discharged from hospital. Provider notifies their staff that a patient has been discharged from a hospital setting. The staff receives information such as the patient’s medication list and discharge summary. They then enter data into a TCM Tracker Excel sheet.
  2. Call the patient. The patient should be called within 2 business days from the discharge to schedule an office visit. This call should be documented in a TCM Flowsheet and TCM Tracker.
  3. Conduct a reminder phone call and pre-visit planning. The staff should confirm appoints 24 - 48 hours prior. The staff should also employ their pre-visit planning protocols.
  4. Conduct a face-to-face encounter. The office visit should now occur, as well as medication reconciliation.
  1. Document patient data in the EHR. Document data such as the date of discharge, the date of the interactive contact, date of the face-to-face office visit, and medication reconciliation.
  2. Bill office codes.Bill for high-risk or moderate-risk.
  3. Tracking the patient. Populate the TCM Tracker Excel sheet. Review it weekly to identify patients who should be contacted.
  4. Care management and follow up. Call patients to follow up on their care. Have they been readmitted to a hospital? Does the patient present any needs that should be addressed? Responses should be documented in the TCM Tracker.
  5. Reporting TCM efforts. Produce run charts to show improvement in 30-day readmission reduction. Use the TCM Tracker as an ROI calculator.

Transitional Care Management in Action: A Case Study

Dr. Narcisa Murillo, MD, is a solo provider who has two offices in New Jersey. Dr. Murillo joined the Garden Practice Transformation Network (GPTN). GPTN was created as part of the Transforming Clinical Practice Initiative (TCPI). After discussing transitional care management with her GPTN consultant, she determined TCM wasn’t being provided to patients with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making.

First, Dr. Murillo was shown outlines for a workflow implementation using evidence-based guidelines in addition to a workflow that made it easy to share a patient’s admission date, discharge date, and patient transfer information with affiliated facilities.

Next, daily and weekly staff huddles were implemented to review key areas where patient education was needed. Whenever a patient was admitted or discharged from a hospital setting, they were reminded of how important it was that they contact the practice. Dr. Murillo’s staff displayed informational posters in the waiting areas and examination rooms. Dr. Murillo’s staff also encouraged patients to collaborate with their families in setting goals, making decisions, and managing their conditions using Ask Me 3 as a form of intervention. They’ve also implemented a same-day visit triage protocol that helps identify high-risk emergency room visits. In 2018, the practice was able to prevent 480 patients from going to the emergency room by providing same-day urgent care attention.

Since implementing TCM workflows and protocols and an ROI calculator, Dr. Murillo’s office has increased office visits and decreased emergency room visits. They’ve also strengthened their relationship with their EHR vendor, enabling them to be more data-driven.

transitional care management
Sign Up - Measures Manager™