Transitional Care
Management Services
THE PROBLEM:
Value Based Purchasing (VBP) SNFs are now financially impacted by readmissions to acute care hospitals within 30 days post-discharge.
THE SOLUTION:
Transitional Care Management (TCM)
WHAT IS TRANSITIONAL CARE MANAGEMENT (TCM)?
Our Nurse Practitioners provide TCM services to patients following discharge from a facility to their home or community setting. The healthcare professional accepts the patient post-discharge without a gap. The goal of this patient-centered service is to help reduce the high hospital readmission rates that are seen during this vulnerable transition time for older adults.
Components of our TCM service will include:
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Face-to-face visit with patient
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Medication reconciliation and management
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Patient & caregiver education to support self management, independent living, and activities of daily living
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Review need for or follow-up on pending diagnostic tests and treatments
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Assistance with scheduling required follow up with community provider
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Review of discharge information
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Communication among all involved healthcare professionals
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Assessment and support of treatment adherence and medication management
Process:
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Referral to UHP at Discharge Visit
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Nurse Practitioner will make home visit 48-72 hours post-discharge.
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Bi-weekly phone calls for 4 weeks from staff to identify areas of need.
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Nurse Practitioner weekly visits, as needed, to ensure stabilization
back into home setting. -
Follow up with healthcare professional resuming posthospitalization.
Facts:
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Studies indicate that 46% to 56% of all medication errors occur at a transitional point of care.1
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Up to 75% of Medicare enrollee readmissions are preventable.1
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Up to 45% reductions in readmission rates due to transitional care programs.2
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Fewer than 50% of patients see their PCP within 2 weeks of discharge.2