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Moving from one care setting to another, such as from a hospital to a nursing facility or home care, is a high-risk period for patient safety, which could result in leaving an individual vulnerable to errors or injuries – falls, pressure ulcers, medication errors, or other gaps in care. These issues are generally related to poor communication or result from multiple hand-offs between providers. During transitions, it is critical to ensure the movement between care settings and professionals is thoughtful, person-centered, and set up for success.
Transitional Case Management
Transitional Case Management (TCM) is a specialized healthcare service designed to support patients as they move between care settings. Good TCM reduces gaps in care, decreases hospital admission rates, improves medication adherence, and improves patient safety, enhancing overall patient satisfaction and quality of life.
Components of Effect TCM
A high-quality TCM program is person-centered, employing comprehensive discharge planning and strategies that fit each individual’s unique needs. For instance, if a person is transitioning to home care, evaluating the home for tripping hazards or fall risks, then arranging mitigation of those risks, is essential.
Medication reconciliation is another key component of TCM, ensuring accurate medication lists and proper administration. According to the Agency for Healthcare Research and Quality (AHRQ), an estimated 60 percent of medication errors occur during transitions of care. This can lead to an avoidable hospital readmission or other risk to patient safety.
Follow-up care coordination is crucial to preventing gaps in care. A transitional case manager can assist with scheduling and preparing for post-discharge appointments. They also can identify and assist the individual and their support system with mitigating barriers that might keep them from attending appointments.
Finally, empowering a patient with information about their condition, care instructions, and connecting them to community resources can equip the individual and their support system with the knowledge needed for successful self-care.
TCM Process
A comprehensive TCM process begins upon admission and continues post-discharge. Continuing the process post-discharge allows for the identification and mitigation of care gaps that may not have been present or visible at discharge. The process involves a multidisciplinary team, including nurses, social workers, and care coordinators, who work with the individual and caregivers. At its core, TCM utilizes evidence-based practices to optimize patient outcomes, with those practices tailored to each individual and situation to provide the best possible person-centered outcome.
Implementing TCM
Successful implementation requires dedicated staff, robust communication systems, and a commitment to patient-centered care. Many healthcare organizations partner with specialized TCM service providers to ensure comprehensive, high-quality transitional care. A high quality TCM program can improve quality metrics and patient satisfaction scores, reduce readmission rates and associated penalties, and promote enhanced care continuity and communication across healthcare settings.
By understanding and implementing effective Transitional Case Management, healthcare providers can significantly improve patient outcomes, reduce costs, and enhance the overall quality of care.
TCM at Telligen
Since 2019, Telligen has been providing a Transitional Case Management solution. From our experience, a study conducted from 2019 to 2022 revealed that TCM participants experienced:
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- Lower emergency room visit rates
- Reduced hospital admission rates
- Decreased hospital readmission rates compared to a non-participant control group.
TCM program patients have achieved an impressive 80 percent follow-up rate, with participants aged 18-64 successfully connecting with healthcare providers after hospital discharge.
If you’d like to know more about Telligen’s process and outcomes for transitional case management, please contact us today to speak with one of our experts.