Medicare beneficiaries who have medical and/or psychosocial conditions can benefit from the management and coordination of care during the transition from a hospital or other health care facility to a community setting (e.g., home, assisted living facility, nursing home, etc.).

The service to coordinate this care is called transitional care management (TCM). It ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. TCM services may include contacting the patient or caregiver after discharge to reconcile medications, scheduling primary care visits, and/or developing a plan to coordinate with other care providers.

The Centers for Medicare & Medicaid Services (CMS) began paying separately for TCM services in 2013. The American Academy of Family Physicians (AAFP) supports the separate payment, as it provides family physicians additional revenue to offer patient-centered, team-based care.

The AAFP’s TCM Toolkit provides further details beyond the scope of this supplement about TCM. Among other resources, the toolkit includes a step-by-step process, component and requirement table, and patient brochure.

Connect MACRA to TCM

The Medicare Access and CHIP Reauthorization Act (MACRA) established the Quality Payment Program (QPP), which is the umbrella term for the two new tracks for Medicare payment: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs). Transitional care management services support efforts to be successful in the MIPS track. This supplement provides examples of how the components of TCM services overlap with a variety of MIPS reporting measures.

Access full supplement.