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


This 3-month pilot program aimed to increase transitional care management for patients transitioning from an inpatient hospital stay to home for self-care. Improvement of the TCM process allowed for an increase in the TCM billing rate. With the support to continue to improve the TCM process for another 3 months, the goal of a 50% TCM billing rate can be expected. The opportunity of providers using the TCM billing code was a topic of discussion for a few years but getting all the components in place was challenging. The organizational awareness about TCM billing improved due to the sociali zation of a focus on TCM.

Before the project, some PCPs attempted to have their medical assistants perform the follow-up phone contact; however, patients sometimes had clinical nursing questions they couldn't answer. In some clinics, the RN attempted to make the follow-up calls during their workday. However, this was an inconsistent process. After the pilot, the RN-CM consistently performed the outreach call assuring better TCM.

The TCM pilot program's long-term goal is to reduce the annual readmission rates from the current rate of 15.5%. The short 3-month pilot provided preliminary results showing a trend in the readmission rate. While capturing an overall valid readmission rate, an annual rate must be obtained.


The CMS is implementing Bundled Payments for Care Improvement initiatives to improve the quality and care coordination at a lower cost when patients are transitioning from an acute care hospital episode (CMS, 2018). The need to improve care coordination to reduce readmission is moving beyond the 30-day readmission period to 90 days. An evidence-based TCM system and improvement in use of financial billing codes, such as the CMS TCM billing codes, are critical to the healthcare organization's economic viability. With the baseline utilization of TCM billing codes of 13% yielding a monthly income of $21,928, the annual gross revenue would be $263,136. The pilot project doubled the rate to 26%, delivering a yearly gross revenue of $330,348. If the organization reaches 50%, the annual gross revenue could be $627,504. The next steps for the organization are to expand the TCM improved process to the remaining hospitals in the south region and then throughout the state to all system hospitals. If the organization grows the pilot project across all hospitals, the projected revenue is $1.7-$2.8 million annually (see Table 3). By developing statewide dashboards, tracking the improvement over time can give the organization actionable data to determine who warrants additional training on the TCM process.