Integration of Transitional Care Management into a Chronic Care Management Program: A Quality Improvement Initiative

Transitional care management (TCM), provided as a primary care service, must be performed in collaboration with the inpatient setting as an effort to decrease care gaps during the vulnerable patient handoff period. The successful integration of TCM into a chronic care management (CCM) program primar...

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Bibliographic Details
Published in:Nursing economic 2023-09, Vol.41 (5), p.244
Main Authors: Jones, Faith M, Gilchrist, Heather K, Holden, Geri, Nelson, Miranda
Format: Article
Language:English
Subjects:
Care and treatment
Chronic diseases
Family medicine
Medical care
Medical cooperation
Medicare
Medicine, Chinese
Methods
Nurses
Quality management
Transitional care
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Summary:Transitional care management (TCM), provided as a primary care service, must be performed in collaboration with the inpatient setting as an effort to decrease care gaps during the vulnerable patient handoff period. The successful integration of TCM into a chronic care management (CCM) program primarily depends upon relationship building and consistent communication with inpatient case management colleagues. This article will describe a nurse-led quality improvement initiative that examines the multidimensional value of TCM integration into an existing CCM program in a rural setting. It will also address how TCM requirements for payment are aligned with a team-based care approach.
ISSN:0746-1739
2995-4053
DOI:10.62116/NEC.2023.41.5.244