Improving Transitional Care Management – A Five-Step Framework

December 21, 2022
KimSu Marder, RN, CCM

Lead Care Manager

Article Summary


Research indicates that one in five readmissions could have been avoided with proper transitional care management (TCM). Given that Medicare readmission costs amount to $2.6 billion each year, decreasing readmissions through transitional care management is a priority for healthcare organizations. This article details a five-step framework that healthcare organizations can follow to set up successful TCM programs.

The framework emphasizes early, proactive care management that integrates hospital efforts with long-term care needs, home care, and other community resources. Once discharge occurs, it’s often too late to put care transition measures in place, resulting in higher readmission rates and higher healthcare costs.

transitional care management

When patients are released from a hospital to another setting, such as a long-term care facility, they are often required to learn copious amounts of information about new conditions and recommended care plans during a particularly stressful time. They may also need to make lifestyle accommodations, integrate new medications into daily routines, and juggle follow-up visits. As a result, readmissions often occur that could have been avoided. Transitional Care Management (TCM) services were developed to support patients during the period between inpatient and community settings, helping healthcare organizations improve the patient experience while avoiding unnecessary readmissions and associated costs. This article outlines a straightforward, five-step framework for delivering transitional care to successfully improve patient health outcomes following a hospital discharge.

The Cost Burden of Avoidable Readmissions

Since the Affordable Care Act was established in 2012, organizations can be penalized financially under the Hospital Readmission Reduction Program (HRRP), which applies to Medicare and Medicaid patients. These costs amount to more than $26 billion each year, and CMS has reported that close to one in five Medicare beneficiaries experiences readmission to the hospital within 30 days. Studies have found that approximately one-quarter of readmissions may be preventable. In one observational study of a total of 1,000 general medicine patients who were readmitted within 30 days, 269 were determined to be potentially preventable because of “gaps in care during the initial inpatient stay.” Another meta-analysis on causes of readmissions found that 27 percent of readmissions across a range of studies were potentially avoidable.

The Institute for Healthcare Improvement (IHI) estimates that a structured and comprehensive transitional care management program can help health systems reduce avoidable readmissions. And because hospitalizations make up a significant portion of annual U.S. healthcare spending—almost one-third of the total $2 trillion, of which the IHI observes “a substantial fraction” is avoidable readmissions—decreasing readmissions through transitional care management is a priority for healthcare organizations today.

Transitional Care Management Framework

Successful transitional care management follows a predictable path, resulting in better patient outcomes at a lower cost. Care managers are integral to achieving successful transitions of care and reducing unnecessary readmission rates. A care manager oversees the transition plan and ensures that each member of the patient’s care team (patient, primary care provider (PCP), specialist, pharmacist, social worker, family caregiver, and any others who will participate in the care plan) are included in carrying out the care plan.

Step 1: Care Management Starts with Admission

When a patient is admitted, the care manager contacts the case manager at the hospital or skilled nursing facility. This initial contact lays the groundwork for a successful discharge that lowers the risk of readmission. The care manager should ask the case manager several questions:

  • What’s the patient’s care plan?
  • What’s the expected length of hospitalization?
  • What kind of care will the patient need at home?
  • Does the patient need to be discharged to a facility other than home, such as a skilled nursing facility or a rehabilitation facility?
  • How will the case manager communicate the discharge plan to the patient, family, or caregiver?

Communication about discharge between the transitional care manager and hospital or facility case manager is particularly critical. As hospital stays become shorter, care is mostly coordinated when transitional care managers encounter the facility care manager immediately upon notice of the admission to collaborate on discharge plans. The care manager, as part of discharge planning, will communicate with the primary care physician and facility care manager to coordinate visiting nurses or other community agencies that will go into the home to help the patient immediately upon discharge. Timely communication with these people and organizations is essential to preventing readmission.

For example, if a patient is discharged on a Thursday, the visiting nurse agency may not get out to the home for an assessment until the Monday following discharge, leaving the patient without care for up to four days. This is an avoidable gap in care that increases the patient’s readmission risk. A transitional care manager makes agencies aware of when the discharge will occur so they can schedule timely visits prior to discharge.

Step 2: Educate on Medications, Access, Reconciliation, and Adherence

Hospital admissions often result in the patient receiving new prescriptions or medication changes. The transitional care manager must cover the following key points regarding medications prior to discharge:

  • Education: The care manager works with the care team to teach the patient or caregiver about all medications—what they’re for and how (i.e., with or without food) and when to take them. This education helps patients and caregivers understand the risks of missed doses and what to do if they miss a dose. Education should be completed prior to discharge. 
  • Access: Access to medication includes both the ability to get to the pharmacy to pick up prescriptions and the ability to pay for them. This is particularly important with certain medications; with antibiotics, for example, a delay or interruption may cause an infection to return. The care manager verifies with the patient or caregiver that they can access and afford their medications or connects them with resources to help, all prior to discharge. 
  • Adherence: Care managers can help patients and caregivers understand the importance of adhering to the medication plan. How likely is the patient to take the medication as prescribed? Is there a literacy or understanding issue that might prevent them from taking the full course of medication or taking it every day at the same time?
  • Reconciliation: Upon or immediately following discharge, the transitional care manager can also collaborate with the facility or practice pharmacist if one is available. A pharmacist can help obtain an accurate list of medications (including new prescriptions, over-the-counter medications, and pre-existing medications) for the patient’s follow-up visit with the PCP. The reconciliation should be communicated to the PCP prior to the follow-up visit (scheduled within seven to 10 days of discharge).

Step 3: Arrange Follow-Up Appointments and involve the PCP

Upon discharge, the care manager makes sure the patient has a follow-up appointment with their primary care provider (PCP) seven to 10 days after discharge. A follow-up call to the patient within two days of discharge is important to assess the patient’s evolving condition, to determine whether the patient was able to access and understand new medications, and to educate the patient on signs and symptoms that should prompt the patient to call his or her primary care physician. Patients should not skip the PCP follow-up, even if they have plans to see a specialist. The PCP is the continuum of care point person, and this person needs to stay informed of all other care to avoid prescription contraindications, conflicting clinical plans, confusing or contradicting patient instructions, and other adverse events. Likewise, the care team pharmacist or care manager must conduct a medication reconciliation to obtain a current list of prescriptions, including any new medications given in the hospital or upon discharge. This medication list should be given to the primary care provider in advance of the follow-up appointment.


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, which can be done by phone, email, or a face-to-face visit within two business days of discharge by a licensed care manager. Second, providers must conduct a face-to-face visit, which can happen in the home, in the clinic, or through eligible telehealth services within seven to 14 days of discharge, depending on the medical complexity. Lastly, medication reconciliation and ensuing management must be furnished on or before the face-to-face visit and can be done by the licensed care manager or another appropriate care team member.

Step 4: Arrange Adequate Home Healthcare

The care manager determines what type of help the patient needs at home and whether they have someone to help. This is critical for anyone in a weakened state who may need help with cooking, dressing, and other daily tasks. These patients may also need someone to check in with them and make sure they’re adhering to their medication plan and follow-up care plans. The care manager also needs to make certain their homes are safe (e.g., handrails where needed and no slippery rugs or clutter to trip on) and that all needed medical equipment has been ordered, such as walkers, grab bars, or commodes. Visiting nurse agencies, elder services, therapy, and social work interventions are all examples of services that must be in place prior to discharge.

Step 5: Have Patients Teach Back the Transitional Care Plan

The final, indispensable step in the transitional care management framework is having the patient and his or her caregiver teach back the care plan. This is how the care manager confirms that they’ve successfully educated the patient on their discharge plans, diagnosis, medication, and when to call their PCPs. It confirms the patient’s understanding of the follow-up appointment with the PCP. The care manager also provides the patient with a way to contact skilled staff with any questions.

Transitional Care Management Is Key to Reduced Readmissions

Reducing avoidable readmissions makes sense for healthcare organizations that want to improve patient outcomes and their bottom line. Implementing this five-step transitional care management framework can improve outcomes, mitigate costs, and provide a financial ROI. It also provides guidelines that transitional care managers can follow to ensure the success of TCM programs.

Additional Reading

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