Improving Care for Patients Transitioning from Hospital Acute Care to Home

Rosha L. Hamilton, DNP, MSW, BSN; Judith A. Walloch, EdD, RN; Karen Lauer, BSN, RN, MSOLQ; Thomas W. Zoch, MD, FACEP, FACP, CPE


Nurs Econ. 2021;39(2):59-66. 

In This Article


The RN-CM was trained on the care management platform that relayed admission-discharge-transfer alerts. This alert triggered the RN-CM to perform outreach activities via phone call to Medicare patients discharged to a home setting. The telephone call interaction was documented in the patient's EMR using the new TCM phone call documentation template. The original plan was for the hospitals to implement a process to schedule follow-up appointments with the PCP before discharge as recommended by Goyal, Hall and coauthors (2016). Still, due to limited resources, the hospitals did not implement this process. Instead, the RN-CM scheduled the follow-up appointment during the post-discharge phone call. This decision was supported by the other researchers (Jackson et al., 2015; Kamermayer et al., 2017; Lin et al., 2011).

The 3-month pilot included a 30-day run out to capture the 30-day readmission rates for the third month. Baseline data indicated 837 Medicare inpatient/observation discharges home and 107 TCM billing claims submitted for 13% and a readmission rate of 15.5%. Over the 3-month pilot the average monthly discharges were 512 and the average TCM billing claim submitted was 134 (26%), double the baseline (see Figure 1).

Figure 1.

TCM Procedure Billing Codes Submitted
Note: This graph demonstrates the number of CMS TCM billing codes and number of providers utilizing the codes for the baseline month and the pilot months of the project.
TCM = transitional care management

Before the pilot program, the organization utilized CMS TCM billing codes at a rate of 13%. After the pilot, the rate increased to 26%. This financial improvement benefit showed an increase from baseline in September of $21,928 monthly to an average of $27,529 following the pilot (see Table 2). During the 3-month pilot, the TCM billing rate doubled without adding additional staff.

Also, the 30-day readmission rate was reduced during the 3-month pilot from the baseline rate of 15.5 % to 14.4% (see Figure 2). The computer trendline shows an impressive decline and reflects the volatile and complex nature of readmissions. While December declined to 10.4%, November rose to 18.7% for unknown reasons. A longer time to monitor sustained impact is needed.

Figure 2.

Percent of Discharged Patients with 30-Day Readmission