What is ‘Transitional Care’ and why did Medicare create the program?
The Center for Medicare and Medicaid services defines Transitional Care as the following:
…services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care from an inpatient setting, partial hospital, observation status in a hospital, or skilled nursing facility to the patient’s community setting.”
If you take a deeper look at the definition, the focus should be on one key phrase; “A patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making.” The phrase moderate or high complexity medical decision making is what differentiates Transitional Care from any other post-acute in home care service.
Transitional Care is not a new concept, however, it is a direct way to positively impact overall patient outcomes and cost efficiencies.
Transitional Care is one solution to the wider issue of preventable hospital readmissions, which became a focus with the advent of the Affordable Care Act (ACA) and subsequent Hospital Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions.
In what way is Transitional Care thought to prevent unnecessary hospital readmissions?
By definition, these very complex patients have multiple co-morbidities and chronic conditions, making it difficult to manage in the home setting, especially after a hospital or other inpatient stay. Many times, these patients are confused and anxious, and even the simplest of issues results in a trip to the emergency room.
By being able to provide comprehensive, continuous clinical oversight during the high risk period of readmission (30 days post discharge), the chances of a preventable readmission is greatly diminished because they have live unrestricted access with a trusted human resource, with whom they have an established relationship with, at all times.
How are discharged patients referred to the program and what does it provide access to?
As an approved Medicare provider, patients are able to self-refer to us. In fact, many of our patients have come to us directly or through their advocate or caregiver.
We also have provider partners, medical groups and practitioners that request services for patients that are currently in an inpatient setting. In addition, healthcare facilities such as hospitals, skilled nursing facilities and rehabilitation hospitals are also able to request services for their patients.
Once a patient is under our care, they are assigned a Transitional Care team, comprised of a specially trained Nurse Practitioner and Registered Nurse. Our interactions with the patient are both proactive and reactive and involve the entire treatment and provider team.
The patient has access to their Transitional Care team 24 hours a day/7 days a weeks for a period of 30 days. This includes both phone and face-to-face visits between the patient and their nurse. In addition to clinical oversight, we provide an extensive level of care coordination, medication reconciliation and disease management education.
Much of what we do involves assessing not only the patient’s physical state, but equally important to the healing process is recognizing and considering the patient’s cognitive abilities, psychosocial needs and home environment.
Once all of these have been assessed, the Transitional Care plan is customized based on the needs of the patient. The care plan also incorporates the patient’s discharge instructions and personal health goals. All of the above help to ensure a successful transition home.
Which patients are thought to recover more effectively in a home setting?
There is no doubt that all patients benefit from recovering at home. Those patients that do not require 24 hour monitoring of a clinician will have positive outcomes recovering at home.
For many patients, there is a definite need for the services of a skilled nursing facility or rehabilitation hospital, but for those patients that may not need that level of care, Transitional Care offers them the option to recover in the comfort of their own homes.
Global Transitional Care (GTC) recently became the first Medicare approved provider group. How did GTC achieve this and what impact will this approval have?
GTC has been in development since 2010. After the ACA and the Hospital Readmissions Reduction Program, there was a realization that there were simply not enough resources on the part of hospitals or providers to create a consistent, comprehensive solution to a $27 Billion problem.
In 2014 CMS, launched the Transitional Care codes, which was a step in the right direction. However, with the complexity of the codes and the current levels of the reimbursement, resources were still an issue.
GTC developed a model, in collaboration with the University of Pennsylvania’s Transitional Care Nursing Team, which allowed for commercial viability, without compromising the integrity of the model. In 2014, we started the Medicare approval process. It took us 14 months from start to finish to get the approval to become the first exclusive provider of Transitional Care services.
As far as impact, we know from previous and current patients, that each and every patient will be impacted. It has already been proven that there is a triangular benefit to the patient, provider and payer. Better patient outcomes, a greatly improved patient care experience, and overall reduction in healthcare costs are all direct results of providing effective Transitional Care.
Specifically for the provider, this means less time needed to track the patient after discharge to ensure proper post discharge care. The impact is universal for all those involved in patient care.
What still needs to be done to improve readmissions and overall patient outcomes?
There are two things that stand out in my mind. The first is education. There is still a lot of confusion as to what Transitional Care is, where it fits into the care continuum, who the Transitional Care patient is and the differentiation between Transitional Care and home health.
Advocacy groups like the National Transitions of Care Coalition (NTOCC), the National Readmissions Preventions Collaborative, thought leaders of Transitional Care, and organizations like GTC that are involved in aspects of Transitional Care, are working to educate the medical community and the patients about the short and long term benefits that Transitional Care provides. But there is still a long way to go.
The more people that understand what Transitional Care truly is, the greater the impact will be for overall healthcare outcomes.
The second is the partnership that is needed between providers and treatment teams to fully realize the extent of Transitional Care. Even though we as a medical and healthcare community have made great strides towards collaborative healthcare models, there is still much work to be done to remove the silos that exist. This is where care coordination can make significant impact.
But in order for this to happen, everyone involved in a patient’s care must be willing to embrace this type of approach. Admittedly, there are still many barriers that need to be overcome in order for a true seamless care continuum to exist, but there are things that can be done, such as providing a care model like Transitional Care, that centers on the patient, that can make a significant immediate impact.
What do you think the future holds for Transitional Care?
There is still much work to be done in this space. Right now, everyone is focused on readmissions for the 5 DRG’s that Medicare has singled out, but there are so many other therapeutic areas that can benefit from Transitional Care, that the possibilities are hard to fathom.
Transitional Care directly impacts readmissions, however, the positive consequences of Transitional Care go far beyond just preventing unnecessary readmission. Besides Medicare beneficiaries, there are other patient populations with an equal level of complexities that can benefit from Transitional Care.
The need for Transitional Care is great, and I imagine and would hope that Transitional Care will evolve and become a standard practice for every patient leaving an inpatient facility with a higher level of complexity. GTC is focused not only on setting that standard of care now, but looking towards the future to expand Transitional Care into other areas as well.
Where can readers find more information?
Our website www.globaltransitionalcare.com is a great resource to learn more about Transitional Care and its many benefits.
About Rani Khetarpal
Rani Khetarpal is Chief Executive Officer of Global Transitional Care, and the visionary behind GTC. With a diverse background in healthcare that spans almost 2 decades, Ms. Khetarpal’s breadth of experience ranges from sales & executive leadership to sales training & talent development to launch strategy & brand execution. Having worked for companies, such as BT Corporate Express, Abbott Labs, Eli Lilly & Co, and GlaxoSmithKline, Ms. Khetarpal’s keen business understanding and insights of the healthcare marketplace has been key in her success within the industry. Respected as a leader, she has a commitment and track record of success in delivering positive results in a very dynamic and ever changing marketplace.
Ms. Khetarpal is also active within her community and serves on the Board of Directors for the San Clemente Aquatics team, is past President of the SCA Boosters Organization, is on the Board of Advisors for the Sales Leadership Alliance, is a member of the American College of Healthcare Executive, and a member of the Healthcare Business Women’s Association. She completed her BS. Business Administration from California State University, Long Beach and holds an Executive MBA from St. Joseph’s University in Philadelphia.
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