The time between being discharged from a hospital and settling into a home care routine can be tricky and confusing for many patients. Moving away from round-the-clock care by teams of highly trained medical professionals to a home or assisted living setting is oftentimes shocking and confusing, particularly for patients with degenerative conditions such as dementia, diabetes, etc., and treatment can suffer as a result.
This is where Transitional Care Management (TCM) becomes such an important part of health care. TCM is the practice of easing the transition from the hospital to the home. TCM is typically designed for a 30-day period, and could include any combination of interactive contact, face-to-face visits with medical staff, phone calls, or other types of monitoring. Through this sustained communication and contact, patients are ensured quality of care as they settle in to their homes.
First contact by a medical professional in charge of the TCM process should be made within two business days of the patient being discharged from the hospital. Depending on the condition, TCM may be provided by a wide range of medical professionals, including CNAs, nurse practitioners, and physicians.
The remainder of the 30-day TCM period is often spent connecting with healthcare professionals to ensure continuity of care, getting help with medication regimens, and receiving education and support for treatment and pain management. Face-to-face visits may also be completed, generally within one to two weeks of the patient being discharged from the hospital or clinic.
Patients must be released from a qualifying service setting, such as a skilled nursing facility, inpatient acute care hospital, partial hospitalization, hospital outpatient observation, or inpatient psychiatric hospital in order to qualify.
The primary goal of TCM is to ensure that there are no gaps in the patient's care. As such, the TCM provider will assist with medical decision making during the transition period. The level of medical decision making required to meet the individual patient's needs will be determined by factors such as the number of possible diagnoses or management options, the amount or complexity of medical records and diagnostic tests, and the risk of significant complications.
Transitional care management is an important piece of the puzzle for monitoring and managing chronic conditions. It helps ensure that the patient's needs are being met during the transition from inpatient care to the patient's community setting, reducing the risk for relapse and readmission.
Idaho's leading house call provider since 2013, Keystone Health provides in-home health care and geriatric medicine for home-bound adults with chronic medical conditions: