Transitional Care Management: Ensuring Patient Safety

Transitional care management (TCM) is a crucial component of modern healthcare, particularly for patients with complex medications and/or multiple chronic conditions transitioning from one care setting to another—such as from the hospital to home or from one facility to another. The goal is to ensure continuity of care, minimize readmissions, and improve patient outcomes during this vulnerable period. A multidisciplinary patient-centered approach is key in warranting success.

During transition time, the TCM process helps identify and resolve discrepancies such as duplicate medications, omissions, or incorrect dosages, which can lead to adverse drug events if not properly addressed. TCM includes monitoring, follow-up visits, and adjustments to the treatment plan and medications to assure that patients receive the necessary support during this critical period.¹

Physicians, nurse practitioners, nurses, pharmacists, physician assistants, case managers, behavioral health specialists, and other relevant clinicians and staff play an essential role in a well operating TCM process. This will ensure fewer readmissions to the emergency department and hospital, fewer episodes of chronic condition exacerbation, and lower cost to the patient and healthcare system.

According to studies published by the Centers for Disease Control and Prevention (CDC), about 3.8 million readmissions happened in the United States in 2018 with the average cost of $15,200 per readmission. Heart failure, chronic pulmonary diseases, stroke, and diabetes are among the conditions that may result in early readmission to the hospital. Timely medication review and follow up visits after discharge can significantly reduce the abovementioned problem.^2,3 Other studies have emphasized the importance of TCM, as they showed that 60% of medication errors occur during transitions of care. Also, over 65% of medical adverse events are due to medications.^4,5

Unplanned hospital readmissions within 30 days have increasingly become a key metric for assessing the efficiency and cost-effectiveness of healthcare systems. Health plans use this measure to evaluate how well hospitals and providers are managing care, aiming to reduce unnecessary readmissions and improve overall patient outcomes.⁶  High readmission rates can signal issues such as inadequate care or follow-up, poor discharge planning, or a lack of proper post-hospital support—all of which have financial and quality implications for the healthcare system. In their 2024 report to the Congress, Medicare Payment Advisory Commission reported that Medicare cost due to preventable hospital readmissions has been estimated as $35.7 billion due to 2.3 million readmissions within 30 days from hospital discharge. Since 2012, the Hospital Readmissions Reduction Program (HRRP) has been offering incentives to the health-systems with low readmission rates and enforcing penalties for high readmission rates.⁷  Medicare provided a series of Current Procedural Terminology (CPT) codes to reimburse for timely post-discharge TCM services, including face-to-face and remote therapeutic monitoring. These services assure the early medication reconciliation and necessary follow up visits with either primary care provider or the specialist.⁸

Effective communication between healthcare providers is crucial during transitions of care. Studies showed that timely follow up visits post hospital discharge and timely referrals could significantly reduce the early readmission rates. In one study in 2020, the multidisciplinary approach reduced the 30-day hospital readmission rates from 44% to 19%.⁹

Given all the costs and risks of readmission, TCM is critical for ensuring that patients who move from one care setting to another receive safe and effective care. Well organized multidisciplinary team approach has been shown to significantly reduce 30-day readmission rates, improve patient safety, enhance clinical outcomes, and reduce overall healthcare costs. 

Author Bio:

 

Alireza Hayatshahi, PharmD

Dr. Hayatshahi is an infectious diseases pharmacist. He serves as the Vice Dean of Clinical Affairs at LLU School of Pharmacy. He is a Professor in the Department of Pharmacy Practice, School of Pharmacy, and Department of Dental Education, School of Dentistry. His research interests include interprofessional education, patient-centered collaborative practice, and pharmacotherapy in chronic disease management.

References:

1. Meier M, Simpson G, Patel M, Keedy CA. Impact of Pharmacist Integration Into Primary Care on Reimbursement for Hospital Follow-Up Visits. J Prim Care Community Health. 2023 Jan-Dec; 14:21501319231174768. doi.org/10.1177/21501319231174768.
2. Weiss AJ, Jiang HJ. Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018. Statistical brief #278. Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. July 2021. Accessed June 1, 2024. https://hcup-us.ahrq.gov/reports/statbriefs/sb278-Conditions-Frequent-Readmissions-By-Payer-2018.jsp
3. McDermott KW, Roemer M. Most frequent principal diagnoses for inpatient stays in U.S. hospitals, 2018. Statistical brief #277. Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. July 2021. Accessed June 1, 2024. https://hcup-us.ahrq.gov/reports/statbriefs/sb277-Top-Reasons-Hospital-Stays-2018.jsp
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7. Centers for Medicare & Medicaid Services. (2024, September 10). Hospital Readmissions Reduction Program. U.S. Department of Health and Human Services. Retrieved March 18, 2025, from https://www.cms.gov/medicare/quality/hospital-readmissions-reduction-program
8. Centers for Medicare & Medicaid Services. (July 2024). Transitional Care Manamgement Services Billing Codes. https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf
9. Cavanaugh J, Pinelli N, Eckel S, Gwynne M, Daniels R, Hawes E. Advancing pharmacy practice through an innovative ambulatory care transitions program at an academic medical center. Pharmacy 2020, 8(40). doi.org/10.3390/pharmacy8010040