Transitional Care Management: Unlocking the Key to Better Outcomes (and HCAHPS Scores)

In 2013, the Centers for Medicare and Medicaid Services introduced transitional care management (TCM) codes, a set of services designed to, as the name suggests, improve the care transition following a hospitalization. Since the program’s start, more than 5 million TCM claims have been filed, representing total reimbursement in 2018 of $243 million, according to a recently published JAMA article. These services are limited to patients requiring “moderate or high-complexity medical decision-making” following discharge and are usually billed by primary care providers in an office setting, but specialty practices, nurse practitioners and physician assistants are not excluded.

While they can’t bill for TCM, acute care providers also have a vested interest in better transitions between care settings, says Faith Jones, director of care coordination and lean consulting for HealthTechS3. Not only can they positively impact HCAHPS scores, a 2018 study showed TCM is associated with lower costs of care, mortality and readmission rates. That’s because when TCM services are provided, patients are generally better equipped to manage their care at home, and primary care or specialty providers have a more complete picture of the care the patient received in the hospital. These factors are directly addressed in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey patients fill out after 48 hours to six weeks after being discharged from a hospital.

This survey asks discharged patients a variety of questions about their recent hospital stay, including communication about medicines and discharge information.

But, while the TCM program is more than seven years old, CMS remains disappointed in its utilization. Earlier this year, the agency increased payment and removed billing restrictions for TCM services. For patients requiring moderately complex decision making (CPT code 99495), TCM payments increased from $166.50 to $175.76; for higher-complexity cases (CPT code 99596), the reimbursement rate increased from $234.97 to $237.11.

Starting this year, providers can bill TCM services with 14 HCPCS codes that were previously restricted from being billed with TCM, such as Chronic Care Management, end-state renal disease treatment and prolonged services without direct patient contact. Additionally, the agency established a facility and non-facility payment for TCM.

Despite these added benefits, many providers remain lukewarm about the value of HCAHPS, Jones says: “It’s not just about finances. It’s also a signal to how well people were cared for in the hospital and how well prepared they were to take care of themselves when they got home.”

Take medication misadventures, the umbrella term for adverse drug events, drug reactions and medication errors, which account for about 700,000 emergency department visits a year.

“In transitional care management, we’re making sure the next provider and the patient really understand everything about the medications they’re taking and how they took them in the hospital,” she says. “That’s not just to score well on the HCAHPS survey. It’s about truly impacting people’s lives by keeping them safe.”

One of the barriers to leveraging TCM and HCAHPS is a mindset problem. “When you are sending a patient home, you are still sending them to another provider,” she says. “We talk about the patient being sent home, but that’s not the care setting. They’re physically at home, but who’s responsible for that next level of care? The care does not end when you send them home. There’s always a continuity of care. Considering primary care as an actual care setting that you hand off to is a total mind shift that we have to make. We have to build that bridge.”

Facilitating TCM in an acute care setting starts with ensuring a warm handoff with each discharge. “We do really well with handoffs within a hospital, like between surgery and med/surg, or the ED and a floor,” Jones says. “Hospitals have to make sure they bring the next care setting into that handoff system. TCM gives us that, because faxing a summary report to an office is not enough.”

At a minimum, a warm handoff is direct communication between hospital nursing and a care coordinator in the next care setting (primary or specialty care), including a complete picture of medication and tests (plus results) that were performed in the hospital.

On June 25, Jones will host the webinar, Connecting the Dots Between Transitional Care Management and HCAHPS, to explore in more detail the components of a successful TCM program, including considerations for both acute care and primary care providers. Sign up today.