A sample workflow for transitional care management

Transitional care management (TCM) can improve patient health outcomes, reduce the cost of care, and increase practice revenue. But getting started can be challenging if you don’t have a clear workflow in place that delineates roles and responsibilities.

Here's a sample workflow from a San Antonio-based primary care clinic:

• Designate a TCM patient coordinator (either one dedicated person in a small practice or, in a larger practice, someone chosen each day from a pool of staff members who have been trained to address TCM needs). This person could be a care manager, a licensed vocational nurse, or a registered nurse.

• When a patient has been or is about to be discharged, the acute/post-acute facility partner alerts the practice using a phone number or email address designated for this purpose. The message typically specifies how soon the patient needs to be seen. The TCM patient coordinator monitors these messages and can access the hospital notes and discharge summary for additional details. (Note: Practices will need to work with their facility partners to set up this process and obtain access to patient information for key office staff.)

• The coordinator contacts the patient, family, or caregiver within 48 hours to verify the patient was discharged and verify the plan of care. This EHR template can help. The coordinator schedules a face-to-face appointment to occur within 72 hours, one week, or two weeks, depending on the patient's needs.

• The practice receives daily emails from various payers and acute/post-acute facilities listing admitted patients. This facilitates tracking and close follow-up.

• Most TCM visits can be performed by a nurse practitioner (NP) or physician assistant (PA), who reviews the patients' discharge needs prior to the visit. However, practices should have scheduling options for TCM patients who want to see their primary care physician.

• A follow-up visit is scheduled based on patient acuity, either with the NP/PA for continuity or the primary care physician.

• If the patient doesn't come to the TCM visit, the coordinator calls the same day to find out why and reschedule as soon as possible. To avoid missed appointments, practices can send a reminder email or phone call a day before the visit.

For more information, check out the TCM toolkit from the American Academy of Family Physicians.

Read the full FPM article: “Transitional Care Management: Practical Processes for Your Practice.”