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Transitional Care Management | Value-Based Care

Value-based Care Solutions: Transitions of Care

November 14th, 2023 | 9 min. read



Content Team

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Policy and value-based payment models promote the importance of managing transitions of care. 

Historically, hospitals were the primary focus of Medicare’s Hospital Readmissions Reduction Program (HRRP).  However, consider that one in five Medicare beneficiaries is readmitted to the hospital within 30 days, and a high percentage of these readmissions are considered preventable. 

They cost the US healthcare system about $17 billion annually. Beyond cost, research has shown that 30-day readmissions are an independent risk factor for all-cause mortality that persists for at least two years.

Despite hospitals lowering 30-day readmission rates for Medicare patients from 20% to 17.8%, care coordination between the acute setting and primary care providers is an essential next step in quality improvement.

Research shows that Transitional Care Management reduces readmission rates and lowers mortality

Compelling research highlights the value of improved Transitional Care Management (TCM) for improving overall post-hospitalization mortality.

Here are studies that point to the value of managing transitions of care through this program within a primary care setting:

  • MedPAC conducted research that found the HRRP contributed to a significant decline in readmission rates without causing a material increase in emergency room visits or observation stays or a net adverse effect on mortality rates.
  • Several TCM programs have gone through randomized controlled trials and have been found to significantly lower readmission rates, achieving reductions up to 45%.
  • Another study found that participants in a TCM program decreased their odds of readmission by 86.6%. Only 3.7% of TCM patients experienced a 30-day readmission.
  • A 2020 review of an interprofessional, primary care-based TCM program revealed that patients experienced reduced readmission rates compared to standard follow-up at 30, 60 and 90 days. Follow-up through the TCM program was associated with decreased odds of hospital readmission at 90 days by 60%.
  • One study looked at TCM follow-up after emergency surgery and found that Medicare beneficiaries who received follow-up had a 67% lower readmission rate.

Optimize primary care-based Transitional Care Management to reduce readmissions 

Engaging patients with primary care-based TCM maximizes the role of ambulatory care for improving post-hospitalization outcomes. 

Research has demonstrated several strategies that support an effective primary care-based TCM program to reduce not only 30-day readmissions, but throughout post-discharge follow-up.

Find more excellent value in readmission risk reduction

Past research wondered whether primary care physicians influenced readmission rates. However, one study found there was little variation among primary care physicians.

The Merit-based Incentive Payment System (MIPS) attempted to incentivize readmission reduction through a pay-for-performance program. However, MIPS has not been sufficient to motivate primary care practices to embark on a TCM program focused solely on hospital readmissions.

The government may step up efforts to put performance measures in place for primary care physicians. But, until there’s additional financial value and care quality built into the equation, it will be slow to get primary care on board.

Value-based care is a natural tie-in for TCM as one of several care management programs offered by Medicare

TCM services consist of three segments—interactive contact, non-face-to-face services and an office visit with a physician responsible for the transition. All three elements are mandatory within TCM-specific timeframes, unless determined otherwise.  

In addition to value-based care arrangements, primary care practices can be more competitive in health plan and system negotiations with a TCM program in place. Ambulatory care teams make more attractive partners by demonstrating value-added services that streamline care coordination.

Providing TCM services can also impact other performance measures by avoiding costly readmissions, exacerbations and poorer health outcomes.

Identify readmission risks during hospitalization

Consider starting a new TCM program with a focus on patients who have diagnoses that are included in the HRRP program, such as:

  • Acute myocardial infarction
  • Heart failure
  • Chronic obstructive pulmonary disease
  • Pneumonia
  • Coronary artery bypass graft surgery
  • Elective primary total hip arthroplasty
  • Total knee arthroplasty 

This could be scaled to other conditions as needed over time.

Engage post-admission patients earlier 

Studies have shown that primary care practices have a shorter window to impact readmission risk. 

Quality signals were highest on the first day after discharge and declined rapidly until they reached a nadir at seven days. The study found similar patterns across states and diagnoses.

Additionally, research has shown that after seven days, a primary care practice’s impact, ergo responsibility, essentially decays. After the seventh day post-discharge, readmissions were explained by community- and household-level factors beyond the hospital’s, or primary care practice’s control.

Primary care leaders should consider strategies that connect with patients and family caregivers before discharge and engage immediately after. This window provides the best opportunity to support the transition, avoid readmission and set a path for better health.

Create closer hospital-primary care connections

Providers that track patient hospitalizations and offer TCM early in the patient’s hospital course have been found to be vital

Clinical staff should facilitate TCM by:

  • Connecting with patients before discharge
  • Beginning assessments of the patient’s biopsychosocial needs
  • Obtaining accurate patient or family caregiver contact information
  • Setting up follow-up appointments
  • Initiating communication with the hospital care team
  • Assisting with developing discharge instructions

Proactively educate patients and family caregivers

Practices with an established TCM program can proactively educate patients and their families about hospital readmissions.

Providing resource materials, an after-hours phone number or contact portal enables patients and their caregivers to reach out upon readmission. This helps the care team prepare for what the patient will need throughout their next transition of care.

Build a TCM program that features multiple intervention components

Primary physician–based transitions of care have received less emphasis in healthcare. But successful hospital-based programs engage more deeply with post-discharge ambulatory services. Working collaboratively, inpatient and outpatient transition teams have been shown to have the best outcomes when post-discharge contact utilizes multiple components.

Clinic-based care managers may be a primary point of contact via phone calls, medication reconciliation, addressing transportation barriers and scheduling with social workers and other care team members. 

Narrowly focused TCM programs, conversely, were less effective.

Look beyond Medicare to Medicaid TCM

Most readmission reduction efforts have been focused on hospital efforts for Medicare beneficiaries. A 2020 report by the Agency for Healthcare Research and Quality (AHRQ report), emphasized the role and value of including primary care. 

However, another AHRQ-funded report focuses on evidence-based strategies to reduce readmissions for adults enrolled in Medicaid.

Both approaches rethink primary care's role in preventing hospital readmissions by acting as an “integrator” within the larger health ecosystem. This fits well with value-based care initiatives and models, such as Making Care Primary.

TCM that is adapted for adult Medicaid beneficiaries would put primary care in a critical position  for post-discharge patient care, including:

  • Establishing a unique and standardized post-discharge follow-up visit
  • Leveraging a team-based methodology to ensure high-quality transitions of care earlier during the hospital stay through to post-hospital follow-up
  • Developing a systematic approach to information exchange with hospitals, post-acute care agencies and behavioral and social support agencies.
  • Addressing whole-person needs and social risks that could segue into other care management programs

Establishing primary care’s role and impact on care transitions

There are many points of value for primary care along the inpatient-to-outpatient journey. 

TCM provides a reimbursable model that reduces readmissions and delivers value-based care and performance measures, leading to better post-admission healing and long-term health outcomes.

How ThoroughCare can help

ThoroughCare helps deliver integrated care management services to foster patient engagement and enhance revenue. Our platform provides the digital infrastructure to leverage fee-for-service programs while promoting value-based care objectives.

ThoroughCare supports end-to-end workflow for TCM, including:

    • Tracking and reporting hospital discharges
    • Coordinating time-sensitive transitional care services
    • Simplifying reimbursement with automated CPT code assignment and an audit-proof record of care

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