Implementing Value-Based Care with Transitional Care Management

transition care management

Transitional care management is a great way to provide more efficient and effective healthcare to patients transitioning from a care facility to their homes. Many healthcare organizations are figuring out how to best fit transitional care services into their overall value-based model. Let us check out how they are implementing value-based care with transitional care management.

Implementing value-based care with transitional care management involves four steps:

Identifying Patients Need

The first step in implementing a value based transitional care management is identifying which patients need these services. It can be done by looking at hospital readmissions or analyzing patient data to identify care gaps that could lead to readmissions.

Connecting Patients with an Appropriate Caregiver

One of the excellent ways to offer a value-based care through TCM is by connecting patients with an appropriate caregiver. For example, if a patient has diabetes and has experienced complications during their stay in the hospital, they might need help managing their condition. They could be connected with a nurse or physician assistant who can provide ongoing care at home.

Providing Services Based on Patient Needs

The TCM process begins with a patient assessment that includes reviewing medical records, conducting interviews and performing tests. Once the assessment is complete, the case manager creates an individualized plan of care based on what they learn during this process. It helps provide better care to the patients.

Monitoring Patient’s Progress

TCM value based programs provide support for patients and family members by educating them about their conditions and treatment options. They also provide practical resources such as transportation assistance or equipment rentals to help make daily living easier for patients recovering from an illness or injury.

Final Words

Transitional care management can help healthcare organizations drive greater efficiencies and care coordination for patients with complex medical needs. It can improve patient satisfaction, clinical outcomes and efficiency for long-term benefits.

If you want to collaborate with CHS to provide Transitional care management service to your patients contact us today or book your appointment.