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Transitional Care Management What is Transitional Care Management (TCM)? Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care. TCM Coding The two CPT codes used to report TCM services are: CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge Requirements and Components for TCM -Contact the beneficiary or caregiver within two business days following a discharge. -The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful. -Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately. -Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit. -Obtain and review discharge information. -Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments. -Educate the beneficiary, family member, caregiver, and/or guardian. -Establish or re-establish referrals with community providers and services, if necessary. -Assist in scheduling follow-up visits with providers and services, if necessary. Discharge from any of the following: Inpatient acute care hospital Long-term acute care hospital Skilled nursing facility/nursing facility Inpatient rehabilitation facility Hospital observation status or partial hospitalization Health Care Professionals Who May Furnish and Bill TCM Services: Physician (any specialty) Clinical nurse specialist (CNS) Nurse practitioner (NP) Physician assistant (PA) Certified nurse midwife Non-physicians must legally be authorized and qualified to provide TCM services in the state in which the services are furnished. https://lnkd.in/dK5Z54XE #tcm #transitionalmanagementcare #caremanagement #medicalcoding #guidelines #codingtips #codingandbilling

Connie Jones, RN,MBA, RAC-CTA,QCPConnie Bend TheConnieBendPodcastKim Watson ODPC, NHA, RNKim Odivin, MBA, LNHAGregory James, MBA, LNHA, CDPGreg Davis Greg Forbes James J. Poindexter, MSW, LNHAJamelyn AkinsJamie FagerstromDavid James Gugerty, PhDJoy M.Joy PowersKimberly King MSA, LNHAKimberly S.Drew WilliamsLt Col (Dr.) Olufemi S. OlatunjiMary Kathryn HillSara BoltonRB Bridges 🌟 Title: “Elevating Care: The Five Strategic Elements of QAPI” 📞 Dear Healthcare Leaders and Colleagues, Quality Assurance and Performance Improvement (QAPI) isn’t just a buzzword—it’s the heartbeat of exceptional care in nursing homes. As a nurse consultant with a passion for clinical excellence, I’m thrilled to share the five strategic elements that can transform your facility’s approach to QAPI. Let’s dive in! 🚀 ➤Design and Scope: Comprehensive Excellence QAPI isn’t a one-time event; it’s a continuous commitment. Engage all services and departments—nursing, therapy, dietary, you name it. Think holistically about resident care, quality of life, and individual choice. Set evidence-based goals, targets, and benchmarks. 🎯 ➤Governance and Leadership: Everyone’s In! Seek input from the entire care ecosystem: staff, residents, families—the whole village. Allocate resources for QAPI efforts; it’s an investment in better outcomes. Hold facility leadership accountable—they’re the QAPI champions. And let’s train our staff in the QAPI mindset! 🌟 ➤Feedback, Data, and Monitoring: Eyes Wide Open Systems matter. Monitor care and services vigilantly. Incorporate feedback from caregivers, residents, and families. Performance indicators are our compass—measure them against quality benchmarks. When adverse events occur (because they will), investigate and implement action plans. 📊 Performance Improvement Projects (PIPs): ➤The Power of Solutions PIPs are our secret sauce. When we spot issues, we don’t panic; we gather data. Systematically. We dissect problems, identify root causes, and intervene. PIPs are our roadmap to excellence. 🛠️ ➤Culture Shift: QAPI as a Way of Life Let’s infuse QAPI into our facility’s DNA. Encourage staff to be quality detectives—spot concerns, report them, and celebrate wins. Make QAPI part of morning huddles, coffee breaks, and team meetings. 🌿 https://bit.ly/3T5Kymo www.coreclinsystems.com

👩⚕️ Dive into the future of healthcare with Brandi Clark and Jennifer Croland in this article from Xtelligent Healthcare - Discover how OSF HealthCare is revolutionizing patient admissions and discharges through its virtual nursing program. 🌐✨ #HealthTech #VirtualNursing #Innovation https://lnkd.in/gGqg_zQS

🚀 📝 I'm thrilled to share that our article, "Churning the tides of care: when nurse turnover makes waves in patient access to primary care," has just been published in BMC Nursing! An interprofessional team effort (Ashley Hughes, Ph.D., Houston Lester, Trang Ngoc Doan PHAM, Laura Petersen, LeChauncy Woodard, MD, MPH, Richard SoRelle, Cheng (Rebecca) Jiang,Fred Oswald, Daniel Murphy, Hilary Touchett, Joshua Hamer, PhD, Sylvia Hysong) 🎉 This research highlights the critical role registered nurses (RNs) play in Veterans Health Administration's Patient Aligned Care Teams. Our findings reveal that continuous RN churn significantly impacts patient access to care, particularly in terms of appointment availability. By applying principles from Industrial/Organizational Psychology, we delve into how team stability and staffing dynamics influence healthcare outcomes. I/O Psychology offers valuable insights into workforce development and retention strategies, which are essential for maintaining effective team-based care and ensuring patient access. Check out the full article here: https://lnkd.in/gyBhYtHE #Nursing #Healthcare #IOPsychology #TeamScience #VeteransHealth #PrimaryCare #Research #ProfessionalDevelopment #HealthcareWorkforce #BMCNursing

It’s Healthcare Quality Week! We take this moment to celebrate and acknowledge the importance of our doctors, nurses, social workers, therapists and so many other healthcare professionals who are committed to improving quality of care for all New Yorkers. The Mother Cabrini Health Foundation supports the development of a strong, skilled healthcare workforce by investing in innovative programs that ensure a pipeline of workers, improve access to education and training for high-demand healthcare positions, improves career pathways and strengthens diversity.   Our recently published report with the Center for Health Workforce Studies at University at Albany identifies strategies to better support nurse professionals to address burnout, improve recruitment, retention and their ability to give quality care to everyone in need.   Read our nursing report and learn more about how we support the healthcare workforce: https://lnkd.in/e8XZdeRs #HealthcareQualityWeek #Accesstocare #QualityCare #HealthcareWorkforce #Healthcare

Could General Practice Nurses soon be included within the additional roles reimbursement scheme? Following industry pressure, practices may soon be able to use ARRS funding to pay for GPNs and mental health practitioners. With this move, practices will have more flexibility in how they utilise their ARRS funding, allowing them to take more pressure off GPs and address critical workforce pressures. But putting this into practice means directing patients to the right care, first time – regardless of whether they need to see a GP, a general practice nurse, or if they just need their prescription refilled. Through structured triage and streamlined patient flow management, we’re helping practices to do exactly that. Find out how we can support your practice ⬇️ https://lnkd.in/d7MgPrm #primarycare #NHS #triage #healthtech #digitalhealth #Klinik

Instead of talking endless data about required arbitrary staffing numbers in nursing homes, let’s really dig deep into workforce availability and the healthcare crisis as a whole. We walk the halls of rehabs/nursing homes. We have watched how patients are treated. Some are okay but lacking, because the workforce is burned out while getting little pay. How does setting staffing requirements help the situation? Where do you find willing nurses and CNAs? Consider other avenues of your loved one’s recovery and last stage. CarePatrol of NE Dallas can help. Call 972-472-4274. #seniorcare #assistedliving #memorycare #inhomecare #independentliving #seniorliving #cms #nursinghomes #skillednursing #elderlyrecovery #endstage

In their new Forefront article, Olga Yakusheva and Robert Longyear from the University of Michigan and Avenue Health argue that the proposed alternative payment model for hospital nursing would eliminate the incentive for hospitals to decrease spending on nursing year over year. "Despite widespread recognition of the need to improve clinician work life, it has been largely overlooked in the value-based payment models being used in the US today. Value-based payment models are designed to financially incentivize health care organizations to provide better patient care and reduce costs, thus aligning organizational behaviors and health care markets with patient benefit and value. With more than 4.6 million US nurses providing the majority of hands-on direct patient care across care settings, addressing the well-being of this largest health care profession is critical for achieving the fourth goal of the Quintuple Aim. But for decades, the nursing workforce has been plagued with job dissatisfaction, burnout, and high turnover. More than half of US registered nurses are employed by hospitals, the practice setting associated with the highest nurse burnout rates." Read the full article here: https://bit.ly/44J19C8

Reposting this great work with lead author Kelley Arredondo, PhD and senior author Sylvia Hysong - if you think all types of turnover in a clinic can be treated the same, think again! Our study found this issue of “continuous churn” (ie constantly replacing and losing) an RN may actually be worse for primary care clinic outcomes than other turnover types!! Check out our #openaccess paper now available through BMC Nursing! #teamworkmakesthedreamwork #nursing #primarycare #nurseturnover #humanfactors #healthinformatics #newresearch

Numerous factors can drive the nature and scope of problems around timely discharge to skilled #nursing providers. In a new article, Kaufman Hall managing director Dawn Samaris and vice presidents Jordan Cloch, CPA, and Chris Peltola discuss how to successfully reduce the length of stay and explore how health system management needs to combine performance improvement efforts with efforts to successfully align themselves more closely with skilled nursing providers. #nursingexcellence https://lnkd.in/gv5w_nHC