Transitional Care Management

Transitional care management (TCM) is crucial to improving outcomes for patients with complex healthcare needs. Patients with comorbid conditions often struggle with managing their health during episodes of acute illness, leading to high readmission rates and poor patient outcomes.

TCM addresses these challenges by administering support throughout the entire care continuum as patients move from one healthcare setting to another. Whether transitioning from a hospital to a long-term care facility or returning home after a prolonged hospital stay, TCM ensures patients receive the care they need when they need it – in a setting that best suits their unique needs.

This blog will cover everything you need to know to deploy an effective transitional care management program, including:

Care Coordination and the 30-day Transition Period

The 30-day transition period begins when a patient is discharged from the hospital. During this time, the patient’s care is coordinated by a transitional care manager who must provide interactive communication, both virtually and in-person.

By the end of the 30-day transition period, the patient should receive the care they need to adjust to their new care setting. There are three key components that determine the success of this transition.

  • Patient education and support: Patients and their family members, caregivers, or guardians should be educated on the care plan, the patient’s diagnosis, risk-specific interventions, and self-management tips.
  • Monitoring and evaluation: Diagnostic tests and follow-up on results from previous appointments should regularly be reviewed and monitored to assess if there is a further need for treatment.
  • Coordination of care: Care coordination is the most crucial component in your TCM program. It involves communicating the patient’s needs and preferences amongst interdisciplinary teams to ensure high-quality and high-value healthcare delivery.

Clear and effective communication is key in coordinating care among your inter-professional care team (IPCT) members. A lack of communication between care providers can lead to potential delays in care delivery, avoidable hospitalization, and overall poor patient satisfaction. That’s why it’s so important to close communication gaps by ensuring interdisciplinary teams have full access to the patient’s care plan.

With regular communication between everyone involved in care delivery, comprehensive patient care coordination can be facilitated to ensure your patients are receiving the right care at the right time, as well as receiving the resources to properly manage their conditions.

How to Provide Transitional Care Management

There are various ways to provide transitional care management. Care functions can either be carried out by one transitional care manager per patient or a team of transitional care managers who coordinate care for multiple patients. In a care management team, healthcare professionals with different roles are required to collaborate and plan for effective and timely transition of members to the community through transition activities.

While there is no one-size-fits-all method for running your TCM program, healthcare providers should take the patient’s unique needs and available healthcare resources into consideration.

Common Challenges of TCM

TCM is a proven approach to improving health outcomes and patient satisfaction. However, there are several challenges that healthcare providers should consider in implementing a TCM program.

  • Financial costs: Some healthcare organizations may face financial barriers from the additional costs of hiring medical staff to facilitate transition of care, implementing new telehealth solutions, and providing training to TCM managers and team members.
  • Lack of resource allocation: Staffing shortages, limited community resources from home health agencies and inadequate infrastructure are all factors that need to be considered when allocating resources for TCM.
  • Miscommunication in care coordination: Coordinating between multiple healthcare providers and settings can be difficult. A lack of standardized processes can lead to conflicting recommendations, unclear patient care plans, and inefficient clinical workflows.

Key Benefits of TCM

TCM offers a valuable service to chronic, elderly, and underserved communities by improving health outcomes with high-quality, high-touch care when implemented effectively.

  • Reducing the risk of hospital readmissions for chronic patients: As many as 86% of patients experienced reduced readmissions compared to those who did not engage in TCM services, according to a 2018 study.
  • Increasing access to care for patients in rural areas: By leveraging telehealth, TCM can extend care coordination to chronic patients in rural communities. Telehealth tools enable healthcare providers to consult with patients through virtual visits to increase access in areas where healthcare services are geographically limited.
  • Improving patient satisfaction: With TCM, payors and patients benefit from improved health outcomes and reduced readmission rates. Delivering high-quality healthcare is a competitive advantage that helps with patient retention and referrals.
  • Increasing patient safety: TCM ensures patient safety through collaborative care coordination. With multiple healthcare providers working together to facilitate care transition, the risk of medical errors decreases and provider accountability for patients increases.
  • Reducing the cost of care: As TCM is known to effectively reduce readmissions, providers can utilize the program to avoid value-based penalties that come from hospital readmissions within the 30-day period after discharge.

Billing & CPT Codes for TCM

According to CMS, providers must conduct one face-to-face visit within the timeframe of these two CPT codes used to bill for TCM.

  • CPT code 99495 – TCM with moderate medical complexity requiring a face-to-face visit within 14 days of discharge.
  • CPT code 99496 – TCM with high medical complexity requiring a face-to-face visit within 7 days of discharge.

How Telehealth Supports the Transition

Care transitions are challenging to facilitate in our current healthcare climate due to the rise of chronic conditions and insufficient access to skilled healthcare providers. Telehealth is an invaluable tool in navigating these challenges and ensuring the effective delivery of TCM through improving healthcare access in a convenient and cost-effective way.

Telehealth enables patients who live in rural communities to transition back to their homes easily. Patients have access to healthcare providers at their fingertips without the need to travel long distances. With virtual visits, clinicians can establish strong provider-patient connections while reducing the patient’s burden of traveling. Transitioning patients also receive essential education and support to help them adjust to their new environment with easily accessible online resources.

For patients with chronic conditions, telehealth tools are proven to help patients with chronic care management. In one example, a study examining telehealth’s effects on outcomes for patients with type 1 diabetes recorded an 88% adherence rate for scheduled telehealth appointments, with 100% of patients surveyed expressing their satisfaction with the service.

diabetes glucometer

Ongoing Care Management for Chronic Conditions

After the 30-day transitional period, ongoing care management continues for patients with chronic conditions. In these care management programs, patients are provided services with the goals of improving self-management and reducing healthcare costs. Key components of care management programs include:

One of the most effective ways to manage ongoing care is through virtual care solutions like telehealth. Health Recovery Solutions (HRS) offers a range of telehealth tools that engage patients with care management via tablet offerings, mobile applications, and biometric Bluetooth devices. By actively monitoring patients’ health in a virtual setting, providers can empower them to actively manage their health outside the hospital environment.

Elite Home Health & Hospice is proud to partner with Health Recovery Solutions to bring a comprehensive transitional care approach to your home health services.

4 Tips to Help Your Terminally Ill Loved One Prepare Financially

If you have a loved one who was recently diagnosed with a terminal illness — such as inoperable cancer or Alzheimer’s disease — your life has been turned upside down. Even if your family member struggled with their health prior to the diagnosis, it doesn’t make the situation any easier. In addition to coping with the sadness and anxiety of this difficult time, your loved one will likely need support in preparing for the future financially. This is especially true if the illness came on suddenly or at a younger age.

Elite Home Health & Hospice shares four things that you can do to provide support and assistance to your terminally ill family member.

Handle all tasks and communication with the utmost compassion

Above and beyond anything, show the highest degree of compassion and care in all interactions. As you handle tasks that can be emotional for both you and your family member, be aware of how you are communicating. Avoid showing too little emotion, as this can come off as unfeeling and hurtful. Aim to be a steady source of confidence and love through these challenging end-of-life tasks.

Find ways to help your family member pay for their medical bills

Expenses associated with terminal illnesses are often astronomical. Bills that amount to hundreds of thousands of dollars are often commonplace in these situations. Medications that provide some level of relief from pain and suffering can cost hundreds or even thousands of dollars for every refill. At a time when your loved one is already experiencing such massive distress, the last thing they should have to think about is paying their medical bills.

If your loved one needs extra funds to pay for their prescriptions and medical care, there are options available for most individuals. One popular choice is home refinancing. Refinancing either your home — or your family member’s home — can quickly free up equity for immediate expenses. Research the best refinance rates to ensure that this is the option for you.

Establish end-of-life arrangements

Another incredibly important set of tasks to handle as soon as possible are end-of-life arrangements. This includes everything from creating power of attorney, to planning and funding funeral arrangements. Most people plan to fund funeral arrangements via life insurance, though you may have to change policies after a diagnosis. In such an instance, it’s critical that you fully understand the terms of the new policy and make sure not to cancel the old policy until coverage begins.

When signing so many documents, one option to consider is using an online tool for digital signing. This makes it easier to provide legal signatures for important documents without having to worry about printing and mailing.

It’s also important to plan for or work through selling or closing a business your loved one owns. This can be a relatively simple matter if ownership is in a corporation held in stock. Other business structures can be more complex and may require legal assistance.

Of all of the things you will need to help your family member with, this will almost certainly be the most emotionally challenging. Prepare yourself for these tasks by reaching out to your support network of friends and relatives. Also, if you find yourself struggling most days, consider working with a counselor to cope with your feelings.

Ensure that their will is up-to-date

Revisiting your loved one’s will is a particularly critical task — especially if they have a considerable amount of assets. Without proper designations, some or all of their property could go to the state. Hire an experienced attorney to guarantee that the will is updated in such a way that is legally binding.

Although it can be next to impossible to think about anything other than your terminally ill loved one at this time, addressing the above tasks is an absolute must. Part of honoring your family member is doing everything you can to ensure that their last wishes and requests are granted. As difficult as that is, knowing you helped your loved one when they needed it most can be a great source of comfort in the years ahead.

For trusted home health, palliative care, and hospice servicer, visit Elite Home Health & Hospice today!

Heart Health: Preventing Cardiovascular Disease

You can take steps to protect yourself from developing cardiovascular disease, even if you are at risk. The best way to prevent this condition is by following a healthy lifestyle, which includes not smoking, exercising regularly, eating a balanced diet and maintaining a healthy weight as well as getting enough sleep and regular checkups with your doctor.

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Is Telehealth really a good option?

You might wonder if telehealth really is a valid option for seeking healthcare and the opinion of a professional if they are unable to see you in person. Here are some guidelines we use when considering if telehealth makes sense for our patients.

Constitutional: e.g. well-nourished, well-developed, well-appearing, Vitals

Ears, nose, mouth, throat: e.g. normocephalic, atraumatic, external ears normal
by inspection

Eyes: proptosis, extra-ocular eye movement intact, nl sclerae, conjunctivae not

Neck: visible goiter, range of motion of neck

Respiratory: comment on increased respiratory effort

Cardiovascular: patient can palpate PMI

Chest/Breast: e.g. gynecomastia, symmetry

Gastrointestinal: e.g. no caput medusae, no tenderness with self-palpation in
supine position

Genitourinary: visual exam of external genitalia

Musculoskeletal: ROM (active & passive), nails/digits

Lymphatic: Large lymph nodes can be visible

Skin: rashes, ulcers, varicose veins

Psychiatric: anxiety level, affect, memory, tangential conversation

Neurologic: motor deficits, select cranial nerves (e.g. sticking out tongue)

Systems that allow us to gather crucial data, like vitals, facilitate the option for telehealth. Elite Home Health & Hospice pursues telehealth by issuing a system which can support weight tracking, blood pressure recording, pulse oximetry, and heart rate. Telehealth requires patients to participate in their health care assessment, sometimes by being hands on, such as depressing the skin in the shin to show edema.

Using the camera on a phone can facilitate assessment of foot ulcers: Have the patient put the camera on the floor and show you
the bottom of their feet, top of scalp, nape of neck (acanthosis), close-ups of body areas that trouble them, neurologic and musculoskeletal exams: Have the patients move their extremities for passive and active ROM etc, and even GI: self-palpation under supervision may help document rebound, guarding etc, and using a coin/ruler can help create context of the size of a lesion.

Telehealth is a brand new world in healthcare. We are excited to participate in the first steps and bring care to our communities in new ways.



Reduce Hospital Readmissions with Remote Patient Monitoring

Located in Pittsburgh, Home Health and Hospice (AHH) provides a wide variety of care services, including skilled nursing, physical and occupational therapy, speech therapy, hospice, and more. AHH utilizes advanced technology in its clinical care programs to deliver personalized care to support patients in managing chronic diseases and recovering from an illness or surgery. 


Serving communities across western Pennsylvania, including several rural communities, AHH recognized several barriers that many of its patients face when accessing health care services, including lack of transportation, increasing cost of care, and inadequate educational resources available to patients. To address these problems, AHH launched a telehealth and remote patient monitoring (RPM) program in 2019.

However, AHH continued to face the following challenges when deploying RPM services to patients.

  • Wireless Connectivity: Poor connectivity delayed the transmission of patient data and prevented the use of virtual visits meant to provide convenience to rural patients.
  • Lack of Proper Educational Resources: Without educational resources available through RPM, AHH struggled to develop disease self-management skills among its chronic care patients.
  • Reduce ED visits through monitoring and early community intervention.
  • Clinician Buy-in: Lacking educational and clinical support from its previous telehealth and RPM vendor, AHH experienced low buy-in among clinicians, derailing program success.


In January 2021, AHH partnered with Health Recovery Solutions (HRS) to re-launch its telehealth and RPM program. Through its partnership with HRS, AHH aimed to reduce care costs leveraging virtual visits, decrease hospital readmissions and adverse outcomes with real-time biometric monitoring, and support clinicians by providing advanced training and best practices for telehealth and remote patient monitoring.

AHH experienced a seamless transition to Health Recovery Solutions, including

Enhanced wireless connectivity through HRS’ 4G wireless capabilities and SIM card offering, allowing AHH to provide virtual visits. 

Increased access to condition-specific educational resources to improve patient education and strengthen disease self-management among AHH patients. 

A robust onboarding process, offering technical support, marketing resources, logistics and inventory management, clinical and reimbursement consultations, and a telehealth and RPM certification program. 

The ability to personalize telehealth and RPM services through condition-specific care plans and education.

Elite Home Health & Hospice has partnered with Health Recovery Solutions to support a robust telehealth service as part of our home health service line. If you would like more information about how to access these unique services, send us an email at

Answers To Your Top FAQs

Home health care offers a convenient and effective alternative to traditional medical care settings for those in need. By providing personalized care in the familiar surroundings of home, it promotes independence, improves quality of life, and facilitates the healing process.

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