Transitional care management (TCM) is a primary care service, and the payment model agrees. The inpatient setting is penalized for readmission, whereas the primary care setting is rewarded. This poster will shine a spotlight on why and how ambulatory care nurses must lead the TCM process. The poster will discuss building expectations and relationships with inpatient case management colleagues to ensure that an effective handoff is completed to prevent care gaps during one of the most vulnerable times for patients – transitions of care. The poster will also address how the TCM requirements for payment are aligned with the care models that highlight team-based care and having the ambulatory care nurse work to the highest level of education and training. TCM has been a reimbursable care coordination model since 2013, yet 10 years later, many primary care practices have not embraced this service. Our Medicare beneficiaries still have an almost 20% readmission rate. The time is now for ambulatory care nurses to lead this process to improve patient outcomes and improve their quality of life.
MSN, RN, NEA-BC,
Director of Care Coordination and Lean Consulting,