Leveraging Transitional Care Management to Prevent Readmissions and Coordinate Care

November 12, 2020

Transitional care management (TCM) is an opportunity for primary care providers (PCPs) to engage and actively manage Medicare patients after a hospitalization or inpatient facility stay to prevent avoidable readmissions.

COVID-19 Update – June 2020

This article was originally written in February of 2020, and deserves a COVID-19 specific introduction in light of all that has happened since. TCM has always been an important part of the work Aledade ACO physicians undertake. It is a meaningful intervention that can help vulnerable patients through a confusing series of events on the road to recovery. In the time of COVID, it is even more critical that these visits be prioritized in primary care practices. Historically, one of the most difficult challenges that practices have faced in conducting these visits is the patient’s ability to physically come into the office shortly after being hospitalized. With special rules enacted during the national health emergency, Medicare patients can participate in TCM visits virtually through telehealth while remaining in the comfort and safety of their own homes. 

For many patients, a hospitalization is a disruptive and disorienting event.  In addition to the distress of the condition that brought them to the hospital, patients are often required to absorb a huge amount of complex information, within a short period of time, from new diagnoses and medications to follow-up appointments, equipment and lifestyle changes.

Even though hospitals do everything they can to make sure that their patients are discharged with a plan for their continued care and the skills and knowledge about what they need to do after discharge, patients can find it extremely challenging to understand and adhere to new routines and requirements – especially if their PCP is left out of the loop and there is no follow-up or guidance during the transition period.

CMS has reported that close to one in five Medicare beneficiaries experiences a readmission to the hospital within 30 days, costing the healthcare system more than $26 billion each year. More than half of those individuals did not have any contact with their primary care provider after discharge.

“Many of these 30-day readmissions could be prevented through the implementation of transitional care management (TCM) services,” says Catherine Olexa-Meadors, VP of Product, Transitions of Care, and High Risk at Aledade.

“Population health programs can be effective at preventing hospital care and unnecessary costs, but the fact is that some patients are going to be hospitalized,” she said. “You can’t prevent all hospital and inpatient facility-based care. The question then becomes how to best manage the needs of those patients who do go into a facility as they are returning to the community.”  

“How can we make sure that we are closing the loop on the continuity of their care by following up after an event and making sure they don’t end up being readmitted due to something preventable? That’s where TCM comes in.”

What is transitional care management?

The primary goal of TCM is to prevent avoidable readmissions. TCM includes services provided to and for patients during their transition from certain inpatient facility settings (e.g., acute care hospital, skilled nursing facility, inpatient rehabilitation facility) back to their community setting (e.g., home, assisted living facility). 

When agreeing to provide TCM, a PCP is accepting the handover from a facility and assuming responsibility for the patient’s care during the 30 days following discharge. A PCP who provides TCM maintains continuity of care during the post-discharge period and identifies and manages issues leading to avoidable readmissions early, often preventing a return to an acute setting.

Healthcare providers in any specialty can provide TCM services, but primary care providers (PCPs) are particularly well-positioned to take the lead as the ‘air-traffic controller’ for their patients.  

“It’s an incredible opportunity for PCPs to get engaged and reconnect with the hospital so that they understand the patient’s discharge plan and have the chance to double-check any new diagnoses, conduct medication reconciliation, and learn about how to best meet the patient’s ongoing needs,” explained Olexa-Meadors. 

“And it’s especially important if you are participating in an accountable care organization (ACO) or another value-based care model,” she added.  “ACOs need to have that other bookend of care coordination when someone does get admitted and then discharged, because they are accountable for that, too.”

Medicare coding opportunities and requirements

Medicare has established two CPT codes (99495 and 99496) to reimburse providers for providing TCM services that can have a positive impact on reducing avoidable 30-day readmissions. 

The requirements of the TCM codes include interactive contact, a face-to-face visit, non-face-to-face services, and medication reconciliation. First, an “interactive contact” with the patient and/or caregiver must occur. It can be done by phone, email, or a face-to-face visit within 2 business days of discharge.  A licensed clinical staff member is the most appropriate to perform this, though the rules can allow some flexibility for clinical supervision of the outreach by unlicensed clinical staff following the ‘incident-to’ guidelines.

Second, providers must conduct a face-to-face visit, which can happen in the home, in the clinic, or through eligible telehealth services.  For medical decision-making of moderate complexity during the TCM service period, the face-to-face visit must happen within 14 calendar days of discharge.  For medical decision-making of high complexity, it has to occur within 7 calendar days. There are two (2) different codes each with a different reimbursement rate associated with the complexity of the patient.

Third, non-face-to-face services must be furnished by the PCP and/or their clinical staff for the patient during the 30 days after discharge, when indicated.

Lastly, medication reconciliation and management must be furnished on or before the face-to-face visit.  

“These are relatively simple interactions, but the return on investment is significant,” stressed Olexa-Meadors.  “Readmission costs are enormous across the United States.  In New Jersey, as an example, the average cost for readmission in our ACO last year was upwards of $17,000.”

“Aledade has completed an impact analysis on this topic, and it turns out that if you focus on high-priority TCM patients, you only have to conduct around seven TCM visits to prevent that $17,000 in average spending.  That’s a pretty compelling argument for doing this.”

Overcoming the challenges of identifying TCM opportunities

Despite the incentive to use these codes and services to reduce costs and improve patient outcomes, CMS has seen relatively slow uptake of TCM, Olexa-Meadors observed.

“It’s not because PCPs don’t buy into the concept or they don’t want to do it,” she said.  “We have seen practices that are completely bought-in to the idea of TCM, but they don’t always have access to the data they need to act quickly enough to meet the 2 business day interactive contact requirement.”

“We see some groups that believe they’re doing really well with TCM, and that truly think they’re connecting with 100 percent of their eligible patients.  But they’re actually only reaching 20 or 30 percent of the people who could benefit from TCM.  They simply don’t have visibility into everyone who is utilizing hospital or inpatient facility services in real-time.”  

Access to this near real-time data is essential for meeting the deadlines and achieving the goals of TCM for Medicare beneficiaries. Obtaining these notifications from local hospitals can be challenging and time-consuming for a primary care practice, and not all hospitals proactively build this type of functionality today. This process will likely become more standard as we head into 2021, as a new condition of participation goes into effect for hospitals participating in Medicare.

“Aledade can help primary care practice with getting access to this information,” she explained. “We are connected to over 20 external data partners across our 27 states to deliver real-time notifications to partner practices about hospitalizations, emergency department visits and skilled nursing stays. We work with every major state HIE in our regions, and other entities with data access who can provide insight into these utilization events.”

“Our practices use the Aledade App to get notified about these opportunities so that when the discharge clock starts ticking, they can make their calls and schedule their face-to-face visits right away. We also offer insight into which patients are higher complexity and a higher priority, so it gives providers the ability to focus their resources on patients who may benefit the most from these services.”

Integrating TCM into the workflow and connecting with patients

Busy primary care practices may be concerned about the additional time and effort involved in completing TCM activities, but these challenges can be overcome, said Olexa-Meadors. CMS did recognize that there is additional time and effort expended when providing TCM services than is involved in a typical office visit. For this reason, the TCM visit reimbursement is about 50% higher than a comparable Evaluation and Management (E/M) code for most practices, and the reimbursement rate has increased again in 2020.

“I’ve been pleasantly surprised to see that access and scheduling is not as much of a barrier as one would think,” she said. “The weekly volume of high priority TCM-eligible patients for any given practice is not overwhelmingly high.”

A single-site practice may have between five and ten eligible patients a week, she estimated.  “If you think about that compared to the typical number of patients in a day – 20 per provider, maybe – it’s not an unmanageable number.”

A variety of clinical staff can conduct the interactive contact portion of the TCM service with the appropriate supervision and billing considerations, CMS says.  This creates more opportunities for practices to engage patients without overwhelming the schedule of any single clinician.

Practices also have flexibility when working TCM appointments into their schedule.

“Some of our practices will block off a few slots a day at a specific time, say 1:00 to 2:00 every day,” Olexa-Meadors said.  “Others will keep openings on more of a rolling basis.  To be honest, we have heard feedback that it is typically more difficult to convince patients to come in within the required timeframe than it is to find time in the schedule to see them.”

“Patients may not feel the need to visit another doctor after round-the-clock care in the hospital, or when they have a scheduled follow-up appointment with a specialist or surgeon”, she pointed out, “but practices should make a concerted effort to connect with as many individuals as possible and take the lead on guiding the holistic picture of their care.”

“There’s almost always something that is going to slip through the cracks for a patient with multiple concerns or serious health issues,” she said.  “Even if the patient thinks everything is fine, it’s helpful to have a second set of eyes on their medication reconciliation and their resources to care for themselves at home.”

“I’ve heard anecdotes of some physicians calling patients themselves if they are resistant to coming in, because it is very compelling for someone to hear the importance of this directly from their doctor.  Sometimes, sharing stories and other things that they have seen in the past can help convince a person that this is necessary – and almost every provider has at least one great story about how they caught something important in a TCM visit that would have been missed.”

Conducting timely TCM services is a high-value, low-investment initiative that is associated with positive clinical outcomes for Medicare beneficiaries, has been shown to reduce preventable readmission costs in general, and has delivered good financial returns on investment.

“Even if you are not participating in an ACO yet, TCM is a way to put your arms around your patients and create better experiences for them,” Olexa-Meadors concluded.  “You can start to embrace that value-based mindset while also seeing some clear-cut, near-term benefits for your practice and your patients.”