Name of the Procedure:

Transitional Care Management (TCM) Services

Summary

Transitional Care Management (TCM) Services are designed to ensure the smooth transition of patients from a hospital or other healthcare facility back to their home or another community setting. This includes direct communication with the patient and/or caregiver within 2 business days of discharge and involves making medical decisions that are of at least moderate complexity.

Purpose

TCM Services are aimed at reducing the likelihood of readmission and ensuring that the patient continues to receive appropriate care after discharge. The primary goals are to address the patient's medical and psychosocial needs, adjust treatment plans as needed, and provide continuity of care.

Indications

• Recent discharge from an inpatient hospital stay
• Transition from one healthcare setting to another (e.g., from a hospital to home)
• Complex medical conditions that require ongoing management and coordination
• Patients with multiple chronic illnesses or those needing post-discharge follow-up care

Preparation

• No specific fasting or medication adjustments required
• Ensure that all discharge instructions and medical records are provided to the TCM coordinator
• Schedule initial follow-up appointments as recommended by the discharging facility

Procedure Description

1. Initial Contact: Within 2 business days of discharge, the TCM coordinator will contact the patient or caregiver via phone, electronic means, or face-to-face.
2. Assessment: Conduct a comprehensive review of the patient's discharge instructions, medication regimen, and any outstanding medical or social needs.
3. Follow-Up Care: Arrange for necessary follow-up appointments, diagnostic tests, or referrals to specialists.
4. Medical Decision Making: Evaluate and make medical decisions of moderate complexity regarding the patient’s ongoing care plan, including medication adjustments and additional therapies.

Duration

• Communication and initial assessment within 2 business days of discharge
• Follow-up visit typically within 7-14 days of discharge

Setting

• Initial communication can occur via phone, electronic means, or at the patient's home.
• Follow-up visit usually takes place in an outpatient clinic.

Personnel

• Primary Care Physician (Lead)
• Nurse Care Coordinator
• Specialists (as needed)

Risks and Complications

• Potential for miscommunication if not all discharge instructions are available
• Difficulty in managing complex medication regimes without a comprehensive review
• Risk of readmission if follow-up care is not adequately coordinated

Benefits

• Reduced likelihood of readmission
• Enhanced patient satisfaction and adherence to treatment plans
• Improved coordination of care leading to better health outcomes
• Early identification and management of post-discharge complications

Recovery

• Patients should follow the post-discharge care plan, including taking medications as prescribed and attending all follow-up appointments.
• Recovery time varies based on the underlying medical condition and severity of illness.

Alternatives

• Standard discharge without TCM Services, which may increase the risk of readmission and complications
• Home health services or community-based programs that may not fully cover all aspects of TCM

Patient Experience

• Patients will experience periodic check-ins and follow-ups to ensure continued care.
• Some discomfort may arise from frequent assessments and adjustments to treatment plans.
• Appropriate pain management and comfort measures will be discussed and implemented as needed.