Needs Statement:  

Transitional Care Management (TCM) services play a crucial role in facilitating a smooth transition for patients moving from inpatient to community settings. Following a hospitalization or stay in an inpatient facility like a skilled nursing facility, patients often confront medical crises, receive new diagnoses, or undergo changes in medication therapy. The responsibility of overseeing this transitional phase frequently falls on family physicians. Managing the transitional care of our aging population demands a blend of care, precision, and effective teamwork. Ensuring a seamless handover of care back to the primary care team becomes paramount when a hospitalized patient is ready to return home.

Learning Objectives: 

At the conclusion of the session, the participants should be able to:

• Define Transitional Care Management (TCM) and its core requirements.
• Apply collaborative strategies across the Clinically Integrated Network, physician, and APPs to support seamless transitions of care.
• Identify the appropriate coding process for a Transitional Care Management encounter within the electronic health record.
• Differentiate the required non-face-to-face and face-to-face components of a TCM encounter.
• Apply appropriate documentation practices for a Transitional Care Management encounter.

Target Audience: 

This activity is intended for Physicians and Advanced Practice Professionals.

Educational Methods: 

Lecture