Technology-Enabled TCM: Making The Most Of 30-Day Transitional Care Windows

By Dustyn Williams, MD, DoseDr

The hospital discharge process places patients in a precarious and perilous position. Industry data overwhelmingly backs this reality, fueling national initiatives to improve the outlook on readmissions and adverse events.

Transitions of care sit at the heart of this movement. Data from the Agency for Healthcare Research and Quality make a clear connection between readmissions and clinical process breakdowns, often associated with poor care coordination and communication post-discharge. For instance, a recent study attributed 26 percent of readmissions to medication events that could have been prevented with the right transition and continuity of care strategy.

Because patients are most vulnerable immediately following discharge, many payers have identified the need for a timely follow-up care visit with a primary care physician—now widely recognized as a transitions of care appointment. In 2013, Medicare introduced CPT transitional care management (TCM) codes 99495 (moderately complex) and 99496 (highly-complex) to capture the work involved in managing patient transitions from an inpatient facility to a community-based setting. These codes incentivize physicians to more actively engage in post-discharge care management by allowing them to bill for TCM. A one-time charge allowed over the 30-day period following a patient’s discharge, TCM CPT codes require follow-up appointments within seven or 14 days—depending on complexity.

This is an important step towards better care transitions, yet patients are still left to their own devices for the majority of the 30-day window. Primary care physicians need additional resources to fully extract the value of a TCM strategy and help patients successfully comply and follow through with post-discharge care plans.

Transitions Of Care: The Challenge

The challenge of care transitions is understandable. Patients—especially those with multiple complex, chronic conditions—go from intense, round-the-clock monitoring and careful scrutiny by a multi-disciplinary care team in the hospital to managing their own care at home.

Consider the challenge of medication management. While inpatient, patients are surrounded by a safety net that ensures appropriate medication administration. Medications are double-checked; patient wrist bands are scanned; and patient identifiers are confirmed.

In contrast, patients with chronic conditions must manage multiple medications on their own following discharge. They are typically provided some limited education, then given a prescription for any number of medications. Handed a binder full of information, patients are then asked to recall which medications to continue, which to start and which to stop. They are asked to interpret and navigate medication adjustments, new or discontinued prescriptions and the timeline and frequency for all.

Some conditions—insulin-dependent diabetes, for example—are particularly challenging from a medication adherence standpoint. To effectively manage the disease, patients with severe diabetes must continually monitor their condition and account for the various factors that alter insulin requirements such as food intake, physical activity, current blood glucose reading and even the time of day. Incorrect calculation can lead to adverse health events such as hypoglycemia, or fear of incorrect dosing may lead to noncompliance, both contributing to the costly readmission revolving door that hospitals are striving to close.

Additionally, many patients are discharged from the hospital setting before treatment for an acute condition has ended. For example, a patient originally admitted for an exacerbation of a chronic illness such as chronic obstructive pulmonary disease (COPD) may no longer meet criteria for an inpatient stay but will need to continue a steroids regimen upon discharge. Or, focusing on common diseases of readmissions, this is true of patients with congestive heart failure requiring changes in diuretic dose and holding of certain medications until a certain date.

In a perfect world, all members of that patient’s care team—including the primary care physician—are informed of discharge instructions and changes. Unfortunately, that is not the typical reality in today’s fast-paced, resource-strapped hospitals. That’s why effective TCM has become so critical to patient outcomes. Yet, one visit with a primary care physician post-discharge falls short of a comprehensive strategy that truly moves the needle on outcomes.

Improving Transitional Care Management

TCM is most effectively addressed through collaborative remote patient monitoring and telemedicine services across the 30-day period covered by Medicare. Simply put, the challenges patients with chronic, complex conditions face are present before and continue after a post-discharge follow-up appointment. Ongoing evaluation and two-way communication between telemedicine physicians and patients ensures patients get what they need to stay healthy and providers get what they need to extract the greatest value from TCM.

In the case of the previously mentioned insulin-dependent diabetics, telemedicine tools are proving especially effective in reducing adverse events. Interactive mobile applications can provide patients with real-time feedback, communicating complex medical instructions in an easy-to-understand way to patients at every insulin dose. Patients simply enter their blood sugar into the application and receive instructions on the correct insulin dose. At the same time, the glucose values and insulin doses are stored remotely, accumulating data on the severity of their diabetes and keeping them connected to a provider if questions arise.

A pilot study conducted at the 281-bed CHRISTUS St. Frances Cabrini Hospital, found that a care transition model leveraging one telemedicine tool reduced A1c levels from 9.4 to 6.3. Average blood sugar levels in the sample of patients dropped 100 points from 232 to 132—an accomplishment that often takes up to seven years with traditional approaches.

The good news is that the TCM reimbursement allows primary care physicians to elevate care this way at no extra expense. It’s a resource that allows a practice to bring in outside services to extend the value of TCM beyond the one discharge appointment and truly impact quality outcomes.

Primary care physicians want the best outcomes for their patients, and they want to fully realize the return of a comprehensive TCM strategy. The challenge is allocating the resources needed to continuously monitor patients across the 30-day window without extra burden. Telemedicine tools hold great promise in filling the gap to improve overall collaboration, enhance care coordination strategies and fully engage patients.

About The Author

Dr. Dustyn Williams is a hospitalist at Baton Rouge General Medical Center and co-founder/chief medical officer of DoseDr.