Finally, after a hospital stay, the patient returns home. He’s happy that his condition has improved and happy to be back in his familiar surroundings with his loved ones. However, the patient may soon experience confusion. Although doctors cared for him in the hospital, how can he care for himself at home without the constant support of medical staff? What lifestyle should he adopt? What medications should he take, and what should he do if his condition changes? The patient and his family may be at a loss.
The transition from the intensive care unit to inpatient care, home care, or outpatient care leaves the patient vulnerable. Even small mistakes or delays in treatment can lead to a deterioration in his condition and readmission. Fortunately, a solution has been found! A transition management program is designed to help patients and their families safely navigate this transition. Let’s review transition management recommendations.
How Does Transitional Care Management Work?
TCM is built on three key stages. Let’s analyze them!
- Interactive contact occurs within two business days after discharge. Doctors call, write, or meet with the patient in person. The specialist discusses the patient’s condition, any new symptoms, current medications, and the next steps.
- Outpatient services involve a doctor or nurse coordinating communication with other specialists. They analyze test results and arrange appointments.
- A personal doctor consultation takes place 7–14 days after discharge. It depends on case complexity. The doctor assesses the patient, adjusts treatment, and gives recommendations.
Transitional Care Management Becomes More Popular
The TCM services market reached an estimated $265.5 billion in 2024. Likely, it will grow at a 16.5% CAGR from 2025 to 2034. Why is this program gaining traction? Patients and healthcare providers expect better outcomes. Let’s analyze why. The TCM program was launched by the Centers for Medicare & Medicaid Services in 2013. It aims to strengthen physician coordination, reduce readmissions, and lower healthcare costs. TCM services aim to significantly reduce mortality while providing primary care practices with additional revenue. Continued development of TCM services can further improve patient outcomes and decrease healthcare expenses. What does this service involve?
- Early contact with the patient after discharge (within two business days);
- In-person appointments with a doctor or specialist within 7-14 days;
- Medication monitoring and adjustments;
- Organization and support of all necessary visits and tests;
- Education for the patient and their family to enable them to better manage treatment at home.
How Does Transitional Care Management Reduce Readmissions?
The transition period spans 30 days after discharge. This window is critical because any lapse in care heightens risks. Even with successful hospital treatment, inadequate support at home can trigger relapse.
This program reduces readmission risk. Doctors can identify problems early and help prevent complications.
Patient and family confidence grows. They know that they can always get support. This program provides reassurance, reduces anxiety, and smooths recovery.
Who Works for the Patient’s Benefit in the TCM Program?
There is a team of specialists. A doctor, nurse, pharmacist, and case manager support the patient. Their collaboration ensures a thorough grasp of the treatment plan.
Doctors verify the correct dosage of medications, eliminate duplicate prescriptions, and assist with obtaining necessary medications. This reduces the risk of errors and side effects. This is a very responsible job, as the patient’s health depends on it.
Specialists assess medical indicators as well as psychological, social, and daily factors that have an impact on the recovery process. Every detail matters in health care.
However, it is also essential to educate the patient on how to manage their own condition. Doctors teach self-management skills. The patient learns how to take medications correctly, recognize warning signs, lead an active lifestyle, and prevent relapses.
Family and loved ones often become primary caregivers, so they also receive guidance and support.
Transitional Care Management Requirements
Healthcare providers must adhere to requirements established by the Centers for Medicare & Medicaid Services (CMS). These standards are designed to ensure patient safety, continuity of care, and improved outcomes.
TCM is available for patients discharged from a hospital, nursing home, or certain outpatient settings who are returning to their normal activities.
- Services are provided for 30 days after discharge.
- Care staff must contact the patient or caregiver by phone, email, or in person within 2 business days of discharge.
- The patient attends a follow-up appointment 7 or 14 days after discharge, depending on the complexity of the case.
- Care coordination covers reviewing discharge information, reconciling medications, arranging follow-up care, and collaborating with other providers.
Benefits of Transitional Care Management
The benefits of this approach are significant. Doctors and patients note the following:
- Reduced readmissions.
- Cost savings for the patient and the healthcare system.
- Improved quality of life.
- Effective support for patients with chronic conditions.
- Confidence that treatment continues without delay.
Your Support after Discharge
Are you or a loved one about to be discharged from the hospital? Of course, it’s important to monitor the patient’s condition at home. Make sure they have everything they need for a speedy recovery. You should contact professionals who will handle everything.
At VirtuMedex, we deliver telehealth services to patients. We recognize the challenges of moving from hospital to home. Our Transitional Care Management services strive to make this process as safe and comfortable as possible.
We schedule appointments, oversee medication administration, and facilitate constant coordination among all specialists. Our goal is to make your recovery complete, safe, and successful. We support you, your family, and your caregivers. With VirtuMedex, you can recover with confidence. Contact us!