Passing the Baton: Transitional Care Management and Beyond

Host: Faith M Jones, MSN, RN, NEA-BC, Director of Care Coordination and Lean Consulting


As the healthcare focus changes from a “sick” care model to a population health model and payments follow quality and value, it is essential that hospitals and primary care practices partner to create seamless transitions and unified messaging for patients. Medicare (CMS) has created both\ financial incentives and penalties to encourage care coordination during care transitions. Primary care practices have new opportunities supported by Medicare’s Chronic Care Management (CCM) and Transitional Care Management (TCM) reimbursements. Primary care practices and hospitals that collaborate when implementing a comprehensive care coordination program create a win-win scenario for financial health of both entities and make a huge step towards achieving the triple aim: better health for the population, better care for individuals, and lower costs through improvements. Upon completion of the webinar, the participant will understand:

  1. The essential elements of a care coordination program
  2. The collaboration needed to provide Transitional Care Management (TCM)
  3. The requirements to provide Chronic Care Management (CCM) services
  4. The billing and reimbursement implications of TCM and CCM