Understanding The Transitional Care Management Model

Updated: Oct 21, 2019

Chronic Care Management (CCM) and Transitional Care Management (TCM) are both intended to facilitate care coordination, help patients manage their conditions daily, and decrease hospital admissions. These care management models serve to address health concerns with patients and provide them with the resources to prevent complications. CCM and TCM have overlapping functions that are used to accomplish a shared goal of improving patient well-being. The integration of a Transitional Care Model into EHI’s CCM is beneficial at ensuring patient compliance to care plans.


CCM aims to bridge the gap between healthcare practiced in clinical settings and community settings. Healthcare professionals within the CCM service makes sure that patients are adhering to regimes customized by their physician and actively monitoring their own health needs. These professionals interact with patients to develop ways to incorporate care plans into their healthcare routines and make patients accountable for the engagement with these plans by monthly follow-up phone calls. By taking such preventive actions, CCM attempts to control chronic ailments and minimizes patient admissions into hospitals. Nevertheless, there will always be incidences in which patients require acute, reactive care.


TCM is employed following an episodic health issue with a patient. When a patient is discharged from a hospital setting, they need to participate in comprehensive discharge planning, so he or she can assimilate back into their community setting and diminish their risk of re-hospitalization. Under TCM requirements, nurses must follow-up with patients within 72 hours of being discharged from a hospital. They are also responsible for making appointments within a 14-day time period following a patient’s discharge with their primary physician and other healthcare professionals if needed. Nurses will obtain and review patients’ hospital and discharge information. TCM components, interactive contact, non-face-to-face services, and the face-to-face visit, occur for 30 days, beginning the day of discharge. But if patients do not continue to comply with care plans after that time period, then progress will falter. The components in the TCM pave the way for effective longitudinal care and set-up the foundation for CCM.


The use of both CCM and TCM allows for better patient flow regarding long-term care. Patients need to establish plans that will provide consistent healthcare services, respond to potential changes in the intensity of their chronic conditions, and get them back on track to a comprehensive healthcare schedule. EHI's CCM nurses perform duties that correspond with TCM requirements. For example, the nurses identify patients who have visited emergency medical facilities, notify their practice, and book follow-up appointments when patients have been discharged. Also, if a practice has EHI’s system, CCM nurses can help update medical reconciliation of medications, diagnoses, and care teams. CCM nurses are cognizant of changes in patients’ health statuses and react to mitigate these changes. The TCM model improves how nurses react when patients experience complications in chronic conditions and makes it easier for patients to enter or reenter the CCM program. The addition of a TCM model into EHI’s CCM program better prepares nurses to confront issues that arise in patients and stabilize their chronic conditions.


Christine Potkul


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