Article Archive
November/December 2019

Long Term Care: From Hospital to Home — Implementing Transitional Care Management
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 12 No. 6 P. 8

Transitions from one health care setting to another—such as from hospital to home—are vulnerable periods for patients. This is especially true for older adults, who often have multiple chronic conditions and complex therapeutic regimens. Miscommunications are common during transitions, resulting in mishaps such as medication errors, confusion regarding treatment plans, or missed follow-up visits with the patients’ physicians. Among older adults, poorly managed hospital-to-home transitions have been linked to adverse events,1-3 low patient satisfaction,4-6 and high rates of readmission.7,8

To encourage high-quality transitional care, in 2013 the Centers for Medicare & Medicaid Services (CMS) began offering reimbursement to ambulatory care practices for providing transitional care management (TCM) following patient discharges from the hospital. But few physicians appear to be taking advantage of the new opportunity for reimbursement. According to a 2018 study, physician offices billed for TCM after only 3.1% of eligible hospital discharges.9

According to Neela Patel, MD, MPH, CMD, an associate professor and chief of the division of geriatrics and palliative care at the University of Texas Health Science Center in San Antonio, lack of knowledge about how to implement TCM and the time required to actually do it are major roadblocks. “It takes a lot of time, and it’s not a single person who can do it—it’s a team effort. And there are multiple sites that you have to collaborate with,” Patel says.

But successful transitional care is within reach. Here, physicians share how they made it happen.

First Things First: What Are the Requirements to Bill?
Physicians of any specialty can bill for TCM, as can certain other nonphysician providers, including clinical nurse specialists, nurse practitioners, and physician assistants. Two separate billing codes are available: CPT codes 99495 and 99496. Use of either comes with the following three basic requirements:

• communication with the patients within two business days after discharge, either by phone, by e-mail, or face to face;

• non-face-to-face services provided by the physicians and their clinical staff, including a review of the patients’ discharge documents and assessment of the patients’ medication management and adherence to their treatment plans; and

• a face-to-face patient visit. In the case of moderately complex patients (CPT code 99495), this visit must be within 14 calendar days of discharge; in the case of highly complex patients (CPT code 99496), it must be within seven calendar days of discharge.

The Largest Hurdle
For most physicians, CMS’s first requirement—making contact with patients within two days—is the biggest stumbling block. That’s because providers often aren’t aware that one of their patients has been discharged.

Some hospitals have the communications systems in place to send an immediate notification to affiliated physician offices whenever a patient from those offices is discharged from the hospital, but others don’t get that kind of timely notification. Marc Price, DO, president of the New York State Academy of Family Physicians and a physician in private practice in Malta, New York, says that prior to implementing TCM in his practice, his office often wasn’t learning that one of their patients had been discharged until a week after the fact.

If you’re not getting reliable notification about patient admissions or discharges, the first step is to reach out to area hospitals to establish collaborative relationships. “You have to build networks,” says Nazhat Taj-Schaal, MD, an associate professor of internal medicine and pediatrics at Ohio State University in Lewis Center, Ohio. “Build bridges with local community hospitals and rehab facilities. … Notify other people who are going to be helping you care for this patient that you want to be notified when the patient is leaving their care.”

If there are multiple hospitals in your geographic area, Patel recommends focusing on just one to start. “Once you establish that relationship, it has to be a two-way communication. Your clinic should communicate with the hospital on a daily basis, and the hospital should communicate with you,” Patel says. In her case, one practical way that occurred was by arranging for a care manager from Patel’s clinic to be involved in the case review session for the hospitals’ hospitalist teams every morning. The arrangement has proven beneficial to both sides: the clinic representative can give the hospitalist team information it needs to care for newly admitted patients from Patel’s clinic, and the hospitalist team, in turn, provides the clinic with crucial information it needs about their patients’ time in the hospital.

But building bridges with hospitals isn’t necessarily an easy task. When Price first reached out to the main hospital where his patients were typically admitted, he asked whether they could send his office a notification whenever one of his patients was admitted or discharged, but the hospitals said no. Faced with resistance, Price and his office staff had to be proactive, taking the initiative to call the hospitals regularly. These calls were initially made by a physician assistant or medical assistant, but Price eventually brought on a new staff member who took on the task, which turned out to be key to success. “What really made a big change was I hired a care manager, and she’s been actively calling the hospital,” Price says.

To increase the chances that other medical providers will reach out with information about a patient’s admission or discharge, Taj-Schaal advises establishing a separate phone line for that purpose. “Saying, ‘Call our main office number, and go through all the teleprompts and wait to figure out who to talk to and be on hold’—that’s never going to happen.”

Although reaching out to hospitals is an important step, Patel suggests not stopping there. She and her fellow physicians found it useful to reach out to patients themselves. “We had flyers for them, we educated them, we sent messages electronically to let patients know, ‘If ever you go to the hospital, please let us know,’” Patel says.

Making the First Patient Contact
Once your office receives notice of a patient admission or discharge, the next step is contacting the patient or caregiver within two business days. In Taj-Schaal’s view, this first contact is the most important component of the whole transition care package. “The phone call identifies gaps,” she says. When a patient is discharged home, the communication is usually written, and some information is lost in writing. “[You need a] mechanism to confirm that what you’re seeing in writing is actually what the patient is doing at home and that they have all the tools to do that work,” Taj-Schaal says.

Medication reconciliation isn’t mandated by CMS for that initial contact, but it’s required by the day of the face-to-face follow-up visit with the patient, and many providers find that the first call is a natural time to do it (depending on who is making the call). Patel’s clinic has also developed a detailed list of other information to collect in the call. “You need to verify all the meds, you need to review the discharge summary and see what needs to be followed up on and make sure that they got that DME and that the home health nurse went,” Patel says.

Honing the System and Involving the Wider Team
Implementing TCM isn’t a job for just one person; the entire team of both clinical and office staff needs to be involved for success. Taj-Schaal recommends starting out by talking with the whole team about why transitional care is important during staff meetings. “We explain to our staff how the landscape of reimbursement is changing,” says Taj-Schaal, who is part of an accountable care organization. Although financial concerns aren’t her motivator in offering transitional care, she talks with her staff about the reality that quality of care influences the payments their hospital system receives.

According to Taj-Schaal, it’s important to communicate to each member of the team what they have to contribute. In her clinic, nurses know that Taj-Schaal needs their help with medication reconciliation. They know to collect specific pieces of information from patients in the initial phone call after discharge—what are the patient’s new medications, were anticoagulants started, is the patient having any issues with the anticoagulants, what tests need to be followed up on, does the patient need home health, and so on. The medical assistants know that when patients arrive for their follow-up appointment they need to take the patients’ brown bag of medications to do medication reconciliation. “Every member of the health care team needs to work to the top of their license. That’s the only way the care of complex patients works,” Taj-Schaal says.

The front office staff also needs to be included. “The front desk and our phone room know that if a patient is transitioning from hospital, they can’t just look at my schedule and say, ‘Oh, she doesn’t have anything available for three weeks,’” Taj-Schaal says. In her clinic, the office staff maintains template slots in the appointment calendar specifically for patients transitioning out of the hospital. Those slots stay reserved for hospital follow-ups until three days before the appointment, at which point they become open for regular follow-ups.

Aside from specifying each person’s role in transitional care, another component of transition care is communicating regularly about who actually needs transition care. In Patel’s clinic, this occurs in the form of a daily morning brief where everyone in the office gathers to determine whom needs to be contacted and exactly what follow up needs to occur. The team decides, “Who are the patients in transition that need to be called back on, and are we having any issues in reaching those patients? Who are the patients that need to come in for a transitional care visit? And if they are no-shows—if they do not come to the clinic on the day they are supposed to come—we immediately call to find out. Are they back in the hospital? Why did they miss that appointment?” Patel explains.

Realizing the Benefits
It takes time to implement a successful transitional care process, and physicians should be prepared for ups and downs. “It’s a journey, Patel says. “You’re not going to get the ideal integration and collaboration right off the bat. You want to start small.”

But the effort is unquestionably worth it, Taj-Schaal says. Her team has discovered countless medication errors and medication interactions because of their new processes. “Our experience with these have shown that we have infinitely increased patient safety and effectiveness of care after hospitalizations,” Taj-Schaal says.

Jamie Santa Cruz is a health and medical writer in the greater Denver area.


1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.

2. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):6461-6451.

3. Wenger NS, Young RT. Quality indicators for continuity and coordination of care in vulnerable elders. J Am Geriatr Soc. 2007;55(Suppl 2):S285-S292.

4. Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A, Graham ID. Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition. Med Care. 2002;40(4):271-282.

5. Levine C. Rough crossings: family caregivers’ odysseys through the health care system. New York: United Hospital Fund of New York; 1998.

6. Weaver FM, Perloff L, Waters T. Patients’ and caregivers’ transition from hospital to home: needs and recommendations. Home Health Care Serv Q. 1998;17(3):27-48.

7. Centers for Disease Control and Prevention, National Center for Health Statistics. Health care in America: trends in utilization.  Published 2003.

8. Vinson JM, Rich MW, Sperry JC, Shah AS, McNamara T. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc. 1990;38(12):1290-1295.

9. Bindman AB, Cox DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among medicare beneficiaries. JAMA Intern Med. 2018;178(9):1165-1171.