transitional careAccording to a 2009 New England Journal of Medicine study, hospital readmissions within 30 days cost Medicare more than $17 billion a year. And being readmitted is equally hard on patients.

In 2010, in an attempt to trim back the number of readmissions, the Affordable Care Act began penalizing hospitals that reported an excessive number of patients who were readmitted within 30 days (for certain diagnoses) by cutting their Medicare reimbursements.

This year, Medicare is also addressing the readmissions problem by requiring physicians provide transitional care management (TCM) to all discharged patients for 30 days after they return home. Physicians and their staff can provide this care, which is covered at 100 percent, both in person and by phone or email.

What is transitional care management?

Essentially, it means a bridge of support and care as you make the transition back home, including checking on how you’re doing, making sure you have everything you need, following up on pending tests and treatments, arranging for needed community resources, and more. With this care, you’re more likely to continue your recovery and more easily resume your day-to-day life. If you move to a skilled nursing facility (SNF) in between hospital and home, that facility will provide this transitional care. (While Medicare does not currently require transitional care for patients returning home from a SNF, this requirement is expected to go into effect sometime in the near future.)

Here’s what you can expect

Your physician or his or her staff must check on you within two business days of your discharge. This contact can be done by phone, email or face-to-face in the doctor’s office. Your physician must also see you in his or her office within seven to 14 days of discharge (timing depends on medical diagnosis). Often, the facility discharging you will schedule this office visit before you go home.

Also, during the 30 days after your discharge, your physician and his staff may provide non-face-to-face services, such as reviewing discharge information, following up on tests and treatments, making referrals for community resources, providing education to you and/or your caregiver, helping you access care and services, and more.

When hospitals recommend nursing homes or skilled nursing facilities upon discharge, they are now also required to provide you with the Centers for Medicare and Medicaid’s Five-Star Quality Rating so you can more easily compare those facilities and make a more informed decision.

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