Patient and Caregiver Education
Education is a core component of transitional care. The initial intake and follow-up visits give providers opportunities to thoroughly review diagnostics, treatments, self-care instructions and any signs/symptoms that warrant medical attention. Discussion of the patients' social and living situations helps identify how to best support their needs at home. Caregivers are also educated on how to assist patients to enhance understanding and adherence. Printed materials such as illness overviews, medication lists and doctor contact cards reinforce teachings. Proper education of patients and families correlates with better post-discharge outcomes.

Billing and Reimbursement
Providers who furnish the required Transitional Care Management Services components within 30 days of a patient's discharge or transfer may bill Medicare for these services using current procedure terminology (CPT) codes. Moderate complexity billing (CPT code 99495) applies to the typical TCM case involving approximately 60 minutes spent coordinated care. High complexity billing (CPT code 99496) is used for greater time investment, such as patients with multiple chronic conditions necessitating extensive services. Medicare reimburses an average of $150 for moderate care management and $200 for high intensity services. Many private insurers also cover TCM, although coverage and rates vary. Billing is limited to one TCM episode per 30-day period or hospital stay.

Assessing Impact and Continued Development
While research on transitional care management is still emerging, studies point to improvements in patient outcomes, reduced costs and high levels of patient satisfaction associated with transitional care management services. However, challenges remain to increase provider engagement and ensure this care model reaches all high-risk beneficiaries who could benefit. Medicare continues piloting enhanced transitional care programs with innovative care coordination strategies. The goal is building on successes to better support patients navigating healthcare transitions and reduce hospital readmissions. With refinement, transitional care holds promise to become a mainstay approach improving quality and affordability across our healthcare system.

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