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


Development of TCM processes has been useful for patients and organization, improving the transition of care from acute hospitalization to home. Outreach is smoother and more consistent. Patients have meaningful contact with an RN within 48 hours of discharge, which develops a helping-caring relationship that supports a healing environment. System changes also have increased the number of patients who attend follow-up visits with their PCP. These visits provide for corrective interventions as appropriate after an acute care hospitali zation. The organization realized significant financial gain by utilizing these TCM service codes, ensuring sustainability and possible expansion of TCM services.

Other billing codes are also being underused, such as the chronic care management billing code (CCM). A study in New England of 1.7 million Medicare beneficiaries reported only 0.65% of eligible patients had a CCM claim submitted (Gardner et al., 2018). Healthcare systems are already completing much of the work of TCM services and managing patients with chronic disease. However, healthcare systems need to develop reliable processes to capitalize on patient outreach, documentation standards, follow-up visit appointments, and take the necessary steps to submit appropriate billing codes to receive reimbursement for patient services. Other continuity of care models include telehealth services as virtual care options become available for patient monitoring and virtual provider visits due to the COVID-19 pandemic. However, the future of reimbursement remains unclear; CMS has not yet made decisions about post-pandemic reimbursements.

While the technology exists, reimbursement lags. Technological solutions allow RN care managers to monitor patients while they are at home. For example, patients can digitally take their blood pressure daily and transmit readings to a monitoring platform. This care management platform could alert an RN care manager as needed. This can then prompt the provider to contact the patient to conduct a virtual clinical assessment to determine next steps of care. Patients can be treated with rescue medication without the high cost of an emergency room visit. These types of care services help reduce the cost for patients and healthcare systems. Notably, the benefit is an improvement in care and management of patient medical conditions. Utilizing established billing codes, developing new codes, and continuing temporary pandemic-related codes should be explored to generate financial resources and allow providers to move beyond the four walls of health centers.