8 Recommendations for Improving Transition Care Management in the US


Improving the management of transition care in the US is crucial to achieving better patient outcomes, decreasing readmissions, and reducing healthcare costs. To overcome the obstacles and challenges in implementing effective transitional care management services, here are some recommendations for healthcare providers, policymakers, and other stakeholders:

  1. Enhance care coordination and communication: Establishing centralized communication platforms and standardized processes can improve coordination of care among healthcare professionals and settings. Using secure, user-friendly messaging systems and collaboration tools can also aid better communication and support TCM services.
  2. Optimize electronic health records (EHRs): Improving EHR interoperability and standardizing data-sharing practices can enhance the flow of patient information across the healthcare continuum. This can help providers make informed medical decisions and ensure seamless care transitions between acute care hospitals, skilled nursing facilities, and other care settings.
  3. Simplify reimbursement processes: Simplifying billing and reimbursement procedures for TCM services can encourage more healthcare providers to offer comprehensive TCM. This may involve providing clearer guidance on CPT codes and reimbursement requirements, as well as reducing administrative burdens.
  4. Expand the role of non-physician providers: Expanding the role of nurse practitioners and other non-physician providers can address workforce limitations in TCM. Involving these professionals in TCM can enhance patient care, especially during care transitions and follow-up visits.
  5. Leverage technology and telehealth: Utilizing telehealth services and other digital tools can improve patient engagement, access, and satisfaction. For example, remote monitoring and virtual consultations can assist patients in managing their health and adhering to treatment plans after hospital discharge.
  6. Strengthen patient education and support: Providing comprehensive patient education and support can enhance patient engagement in TCM. This may involve using culturally competent materials, offering personalized guidance on medication adherence, and scheduling timely follow-up visits.
  7. Evaluate and adopt evidence-based TCM models: Implementing evidence-based models and strategies for TCM, such as the Coleman Care Transitions Intervention or Project RED, can help healthcare providers improve clinical outcomes and reduce readmissions.
  8. Promote collaboration between healthcare organizations: Encouraging collaboration among hospitals, primary care providers, and post-acute care facilities can facilitate the sharing of best practices and resources to improve TCM processes and outcomes.

By taking these recommendations into account, healthcare providers, policymakers, and other stakeholders can work together to enhance TCM in the US, ultimately leading to better patient care and satisfaction throughout the healthcare system.
Read our article on Transition Care Management: https://bluestartelehealth.com/transition-care-management/

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