Transitional care has been around for eons. Long before there were nurse navigators or care managers or care coordinators, there were nurses assisting patients and their care givers with discharge from the hospital after an event like surgery or an observational stay. They helped them change back into street clothes from their gown, provided education on their surgical incisions, made recommendations of community resources, gave medication instructions, and offered reminders of followup provider visits. Then, this care evolved to help patients at other pivotal moments in their care such as:

  • Transition from hospital to home health
  • Transition out of/to a long-term care facility
  • Transition to/from a mental health facility
  • Transition to a PCMH
  • Transitions between treatment providers in cardiac disease or cancer.

In 2013, the AMA launched Transitional Care Management CPT codes* to support the services – showing that they valued these high-touch and high-value interactions with patients. Since 2013, transitional care has been finding its niche as the winning role for the System of Care.

Anecdotal benefits of TCM:

  • A 40 percent increase in professional revenue for eligible hospital follow-up visits and a decrease in readmission rates from 13.1 percent to 8.2 percent. (Dr. Lonnie Robinson, a family physician at Regional Family Medicine in Mountain Home, Arkansas)
  • Lower re-hospitalization rates compared with control subjects at 30 days (8.3 percent vs. 11.9 percent) and 90 days (16.7 percent vs. 22.5 percent). The mean hospital costs were lower for intervention patients ($2,058) than for controls ($2,546) at 180 days. (
  • A cumulative per member savings of $2,170 at one year

More than the financial benefits, hospitals and health systems are seeing TCM as a competitive edge. They are integrating Transitional Care coordinators into the complex disease patient’s care pathways for the long haul and not just discharge – many patients get introduced to a TCC as early as a planned admission or a diagnosis. Transitional care coordinators can be lower licensed professionals, reserving the nursing role for clinical intervention and disease management. The TCCs work with case managers, floor nurses, disease-specific navigators & care managers to make sure that the patient is transitioned properly, regardless of the location (hospital, SNF, PCP-to-specialist, hospital to mental health facility, and so on). The TCC patient relationship pays dividends to all involved. Patient-centric transitional care. A winning idea.

*e.g. CPT Code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge. The location of the visit is not specified. Cordata offers Transitional Care coordination in its multispecialty application. To learn more contact