Transitional Care Management Hybrid Approach to Chronic Care Management Successfully Leads to Quality Improvement on the Western Frontier

February 8, 2024

Real-world evidence of the value of the Medicare Transitional Care Management (TCM) Program when provided as a primary care service is successfully demonstrated in the Integration of Transitional Care Management into a Chronic Care Management Program: A Quality Improvement Initiative report. Part of a quality improvement initiative in a western rural health clinic, nurse-authors employed specific strategy, processes and tools necessary to achieve real-world, quality outcomes. Based on TCM services requirements, TCM is seamlessly integrated into an existing Chronic Care Management (CCM) Program in a rural setting. Applying collaborative, team-based approaches, the study discusses TCM requirements for payment.

This is the latest work contributing to the evidence showcasing the importance of CCM, TCM and other Medicare care management programs.

Medicare CCM is a program designed to provide additional support and care coordination for Medicare beneficiaries with multiple chronic conditions. The goal of CCM is to enhance the quality of care and improve health outcomes for individuals living with chronic illnesses. The program offers an incentive payment from the Centers for Medicare and Medicaid Services (CMS) to the specific clinic engaged with providing the service under the licensure of a physician.

The CCM program is available for Medicare beneficiaries who have two or more chronic conditions expected to last at least 12 months, or until death.

To evaluate and compare the quality of health care, Jones et al. employed the Donabedian Model. The inpatient case management colleagues established the efficient integration of TCM into a CCM program by performing consistent communication on a daily basis situated in a rural community in the Western United States.

The remote registered nurse (RN) care coordinator successfully managed the CCM patients. A cloudbased care coordination software supported the entire management of the integrated TCM/CCM program. All TCM regulatory elements scheduled by the case manager were completed in a timely manner.

The authors showed and discussed the results of their team-based approach powered by a cloud-based care coordination platform in the integration process of TCM into existing CCM program in the journal of Nursing Economics. The efficiency of this new TCM/CCM program resulted in more effective hospital follow-up, marked decrease of hospital readmission rate compared to national average, and increased practice revenue through additional reimbursement.

Daniel O’Connor CBO, CrossTx, Inc


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