Transitional Care Management (TCM) programs have been instrumental in enhancing patient outcomes during transitions from hospital to home, notably reducing hospital readmission rates and improving overall care quality. Some percentage of large health systems have effectively implemented TCM initiatives, leveraging their extensive resources and integrated care teams. For instance, the University of Florida Health Jacksonville established a dedicated TCM team focused on standardizing workflows, which led to improved patient outcomes and decreased readmission rates, as well as increased reimbursement.

Implementing TCM programs within networks such as Independent Physician Associations (IPAs), Accountable Care Organizations (ACOs), or Clinically Integrated Networks (CINs) presents unique challenges due to their decentralized structures. However, success is achievable with strategic planning and resource allocation. CrossTx has supported the ramp up of a CIN in Dallas Texas called Aspen Physician Network for example.  Innovista Health, for example, has demonstrated success by embedding case managers within high-volume acute care facilities, initiating comprehensive TCM services within 24-48 hours post-discharge.

Health Information Exchanges (HIEs) have also ventured into supporting TCM programs. In Texas, the health information exchange C3HIE, in collaboration with CrossTx, developed a Transitional Care Management platform, including configurable reporting and dashboards, tailored workflows, configurable programs designed for the specific HIE ecosystem, and industry-standard roles, security and audit trails to assist healthcare providers in managing patient transitions more effectively.  

The HIE partners now plan on expanding.  Cross Tx is also in discussions with multiple other HIES to deploy TCM services across networks.

The success of TCM programs relies on the ability to share patient information seamlessly between different care settings. HIEs play a vital role in facilitating this information exchange, enabling providers to access critical patient data and coordinate care efficiently. 

CrossTx provides a platform for providers to collaborate and implement TCM programs, leading to improved patient outcomes and reduced healthcare costs. 

Performance

The success of TCM programs is often measured by key metrics such as reductions in hospital readmissions, improved patient satisfaction scores, and enhanced care coordination, plus revenue generation via the additional Centers for Medicare and Medicaid Services (CMS) payments.

For instance, comprehensive TCM programs have been associated with a reduction in readmission rates by as much as 86% according to some sources.

Much Needed Reimbursement

As already mentioned, CMS provides reimbursements for TCM services, incentivizing healthcare providers to adopt these programs. Accurate tracking of these reimbursements is essential for assessing the financial viability and success of TCM initiatives.  In large networks the total potential reimbursement can rise to hundreds of millions of dollars.  Not surprisingly few healthcare organizations have scaled at that level, however it’s possible.

TCM Scale-out—Still Early Days

While the exact number of ongoing TCM projects is not readily available, the growing emphasis on value-based care has led to an increase in such programs across various healthcare settings. Formal studies  and vendor promotions identify best practices for TCM, including early patient engagement, comprehensive discharge planning, effective communication among care teams, and the utilization of health information technology to monitor patient progress.

In conclusion, successful TCM programs are characterized by structured care coordination, timely follow-ups, and the integration of technology to facilitate seamless transitions. Healthcare organizations, regardless of size or structure, can achieve significant improvements in patient outcomes and operational efficiency by adopting these best practices.

To learn more about CrossTx TCM programs follow the link.