A service that runs on deadlines
Transitional care management support is mostly deadline management. The service covers the thirty days that begin when a patient leaves a hospital or certain facility stays and returns to a community setting such as home or assisted living, and three of its requirements are on a clock.
Under Medicare’s rules, those are an interactive contact with the patient or caregiver within two business days of discharge, a face-to-face visit within 7 or 14 days depending on the complexity of medical decision making, and medication reconciliation no later than the date of that visit. The practice confirms current requirements with each payer.
A practice that learns about a discharge on day four has usually lost the first window. Gateway’s work is built around that fact: get the discharge information early, put the dates on a list and coordinate the appointment.
Finding out about the discharge
Notification is the hardest part of TCM. We help set up a discharge intake list fed by every source the practice has: hospital and health information exchange notices, and calls from facilities, home health agencies, patients and families.
For each discharge the list records who, from where, the discharge date and the destination. We request the discharge summary and medication list as soon as the discharge is known, since those documents often lag behind the patient. Our guide to building referral relationships with discharge planners describes what hospital and facility teams across Greater St. Louis and the Metro East need from a practice in return.
Tracking the contact deadline
Once a discharge is on the list, the dates are calculated and visible: the last day for the interactive contact and the two possible visit windows. Each contact attempt is logged with the date, the time, who made it and what happened.
That log matters when a patient cannot be reached. How timely but unsuccessful attempts are treated is defined in the billing rules, and the practice applies them. Who may make the contact, and under whose direction, is also set by the rules and confirmed by the practice.
Records and medication-review tasks
Before the visit, we assemble what the clinician needs from the hospital stay:
- The discharge summary and any operative or consult notes
- The discharge medication list beside the list the practice had before admission
- Pending test results and who is responsible for following them
- Follow-up appointments, home health orders and equipment ordered at discharge
- New needs, such as therapy, supplies or wound follow-up after discharge
Medication reconciliation is clinical work, done by the clinician or by qualified staff under the practice’s direction. We put the two lists side by side and mark the differences for review. We do not decide which list is correct, and we do not advise patients about their medications.
Coordinating the appointment
The clinician judges the complexity, which determines the visit window. We schedule inside that window and deal with what tends to cause missed visits after a hospital stay: transportation, a caregiver who needs to attend, a patient too weak to travel. If the patient is readmitted before the visit, the list is updated and the practice decides how that affects the service.
The rest of the thirty days
The service does not end at the visit. Referrals made that day need to be completed, home health and equipment need to arrive, and results that were pending at discharge need an owner. We keep those items open on the list through the service period.
At day thirty, a patient with ongoing needs may be a candidate for chronic care management or advanced primary care management, and the practice decides. Families who want a plain account of this period can read the first two weeks after the hospital.
What stays with the practice
Eligibility, consent, supervision, documentation and billing requirements vary by service and payer, and the practice confirms which apply here. The practice also keeps:
- The clinical content of the contact, the visit and medication reconciliation
- The judgment of medical decision-making complexity
- Whether the requirements were met for a given discharge
- Final coding decisions and responsibility for claims
How an engagement starts
Send a practice support inquiry or call 314-325-0126. We will ask how the practice hears about discharges today, who makes the first call and where the dates are tracked. The usual first step is the intake list, because nothing downstream works without it.
Common questions
What if we learn about a discharge after the contact window has closed?
The practice decides whether the requirements can still be met, and often they cannot. The patient still needs follow-up, so the visit is scheduled and the practice bills for what was furnished. We record how the notice arrived late, because a pattern of late notices from one source is worth raising with that source.
Does a discharge from a skilled nursing facility count?
Medicare’s TCM service applies to discharges from several kinds of stays, including skilled nursing facility stays, when the patient returns to a community setting such as home or assisted living. A move from a hospital into a skilled nursing facility is a different situation. The practice confirms whether each discharge qualifies.
Can the follow-up visit be done at home or by telehealth?
A home visit is an option when the practice offers one, and it suits patients who are weak or have no transportation. Medicare has allowed telehealth for this visit, and other payers set their own rules. The practice confirms what is permitted for the patient’s plan and the date of service.
Can two practices bill TCM for the same discharge?
Only one practitioner may report it for a given discharge period. When a primary care clinician and a specialist are both involved after a hospital stay, it helps to settle early who is taking responsibility for the transition. We note the other clinicians involved on the list, so the practice can make that call.