A transitional care unit plays a vital role in a patient’s recovery on account of providing a proper continuum of care and coordination through transitional care, thus ensuring patients are adequately cared for when transferring between healthcare settings. It is a short-term stay care unit for patients who no longer need acute care but still require therapy services. At that point, they can be transferred to a transitional care unit for an extended stay and continue their recovery.
Involving seniors in these processes makes for smoother transitions. A study sponsored by the Sinclair School of Nursing analyzed care transitions between providers. It gained seniors’ perspectives concerning factors like communication, care choices, family engagement, and the overall hospital transfer experience. The study demonstrates that involving seniors causes fewer disruptions and distress for nursing home residents.
Transitional care units are usually run by a team of well-trained clinical practitioners who assess and create a comprehensive patient care plan based on the patient’s specific medical condition, future treatment goals, and preferences. Patients and their families are also educated on medical and treatment needs, reinforcing the proper continuum of care. This combination of resources and care has been recognized to improve care coordination during care transitions.
Healthcare staff, nursing home staff, and family members stand to benefit from these findings as well, as they indicate that collective decision-making improves communication, which reduces unnecessary hospital readmissions and makes for better outcomes.
Requirements for a Transition Care Center
As mentioned above, a transitional care unit or transition care center is designed to safely coordinate and manage care for patients who transfer from different healthcare settings. Here we will discuss the requirements for transitional care for healthcare providers and patients.
Provider Requirements
Before a healthcare provider can offer transitional care management (TCM), it must meet the following provider requirements:
- Skilled nursing: Not all healthcare professionals can provide transitional care. Only qualified physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives can provide transitional care. So transitional care is limited to those clinical professionals who can administer the appropriate level of skilled nursing care while ensuring the patient care plan is followed effectively.
- Sufficient communication: It is crucial to engage and communicate effectively with patients following their discharge from the hospital. Therefore, healthcare providers must make initial contact with patients within 48 hours after release to document patient conditions.
- Follow-up: As part of the aftercare treatment plan, healthcare providers must also arrange face-to-face appointments within one to two weeks after discharge. It is also customary to arrange virtual appointments with patients so that caregivers can stay updated with any changes in condition via the healthcare provider’s integrated care plan software.
For this reason, healthcare providers need to have an advanced nursing computer software system that can capture and store patient information effectively, making it easier for caregivers to update and access patient data.
- Sufficient services: Most transitional care units will offer multi-disciplinary services catering to different patient needs. Typical services offered in a transitional care unit include:
- Activities of daily living (ADL) services and training
- Skilled nursing services—skin and wound care—administered by qualified clinical professionals
- Personal care services from certified nursing assistants (CNAs)
- Therapy services, including occupational, physical, speech and language, and recreational therapy
- Pathology services
- Medication management
- Medical equipment and supplies
- Food and nutrition services
- Social work and case management
- Consultation services
Besides the provider requirements needed to offer transitional care management, patients themselves must also meet specific criteria to qualify for a stay in a transitional care unit, which we will discuss below.
Patient Requirements
For patients to qualify for a stay in a transitional care unit, they must be discharged from one of the following healthcare providers:
- Skilled nursing facilities
- Inpatient acute care hospitals
- Long-term care hospital
- Partial hospitalization
- Hospital outpatient observation
- Inpatient psychiatric hospital
Due to the range of services offered in a transitional care unit—patients will usually have different healthcare needs—especially older adults with multiple chronic conditions. Therefore, needing multidisciplinary care from different healthcare providers.
One consequence of interdisciplinary care provided by various sources means older patients are transferred between provider settings more frequently, increasing the likelihood of them experiencing care breakdowns. For this reason, it is imperative to implement an effective transitional care management plan that considers patient choices to avoid unnecessary rehospitalizations and adverse patient outcomes.
Contact us here to learn how our long-term care software best serves the needs of transitional care units.
How to Meet Hospital TCU Billing Requirements
A transitional care unit in the context of a hospital, or, a hospital TCU is valuable in that it helps reduce the massive amount of money spent on rehospitalization. Studies show that 19.6% of Medicare patients are readmitted within 30 days after hospital discharge, costing approximately $17.4 billion in unplanned rehospitalizations. This alarmingly high figure led the CMS to evaluate the importance of primary care and care coordination and how these factors can improve patient care to reduce healthcare costs.
In 2013, the CMS developed two Transitional Care Management (TCM) codes (99495 and 99496) to help alleviate healthcare costs. These TCM codes are used to reimburse a transitional care unit for care management and coordination services, thus, reducing the 30-day rehospitalization costs.
For transitional care units to qualify for transitional care unit (TCM) billing reimbursements, they must satisfy the Medicare reimbursement criteria outlined by the American Society of Health-System Pharmacists below:
- Access and review the patient’s discharge documents via the transition care center’s eMAR software
- Analyze the patient’s test and treatment requirements
- Provide patients and their families with sufficient information about their health conditions and treatments
- Form reliable ties with local service organizations and community providers
- Arrange follow-up visits between patients with specialists and service providers
- Participate in face-to-face visits within two weeks of discharge (depending on the patient’s condition)
- Provide transitional care nursing through medicine reconciliation and proper documentation management during face-to-face visits
It’s worth noting that transitional care units that fully support and foster patient well-being and seamless care transitions will receive higher financial reimbursements from the government. This gives healthcare providers more incentive to meet billing requirements, such as accurate documentation, specialist follow-ups, proper education, and valuable community resources.
Of course, smooth care transitions can only take place if caregivers are thorough with patient documentation and can communicate efficiently through an advanced long-term care EMR software system that stores and shares data fluidly. This is why it is essential to implement the right care plan software to ensure proper transitional care management.
The Importance of a Transitional Care Unit
A transitional care unit (TCU) plays a crucial role in a patient’s recovery process by providing a seamless continuum of care and coordination as patients transfer from one healthcare setting to another. By providing skilled nursing care, therapy services, and personalized patient care plans, TCUs allow families and patients to rest assured that they are getting the care they need.
Furthermore, TCUs provide education and support to patients and their families during care transitions, ensuring a proper continuum of care once a patient is discharged from a transitional care unit. This highlights the importance of proper transitional care to safeguard better patient outcomes and improve the quality of life for seniors and other patients.
For more on recent trends in long-term care, read our blog and subscribe to the LTC Heroes podcast.
- Understanding Medicare Guidelines for Physical Therapy in Skilled Nursing - March 16, 2023
- What Is Triple Check in Long-Term Care? - February 28, 2023
- Long-Term Care Billing Guidelines: How To Stay Compliant - February 23, 2023
