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Transitional Care Management: Tips for Better Patient Outcomes

The healthcare industry is composed of many different layers, all of which work together to ensure quality medical and patient care standards. One of the most important, but least known, is transitional care management. This process pertains to the management of patients from one level of care to the next, ensuring that their bodies and care plans are properly transitioned for better outcomes. Transitions can happen from a variety of settings, but they usually revolve around hospitals, care facilities, and the home. 

Transitional care management ensures that all barriers and gaps to care are easily identified so that quality patient experience can be upheld. This leads to the reduction of readmissions, and of course, better health outcomes. However, this process isn’t always easy. 

To help you come up with a comprehensive transitional care management plan, here are some tips to follow: 

Education is key 

People who are hospitalized are constantly under the gaze of professionals. Medications are administered around the clock, ensuring that nothing is amiss. When it’s time to transition to the home or another facility, however, the routine can change dramatically. As such, it’s important to ensure that you invest in patient education, especially when it comes to medication.

Care managers involved in the transition plan must work carefully with the patient, especially when it comes to instructions involving prescriptions. Certain pills can be taken without food, whereas others must be consumed on a full stomach. Schedules are also important, as any missed doses can lead to serious consequences. 

Schedule follow-up appointments ahead of time 

Discharge could mean a variety of different things, and a full recovery isn’t always guaranteed. Once a patient is discharged the transitional care manager must schedule a follow-up appointment, which should happen at least ten days after the transition. This appointment is necessary, as it will help the patient follow the treatment plan laid out for their condition.

Scheduling such appointments earlier saves both parties from the rise of issues, such as confusing clinical plans, vague patient instructions, busy days, and even prescription fiascos.

Ensure a thorough home healthcare plan

Although this depends highly on the patient’s needs, a good transitional plan must consider the presence of another person at home. Some patients will have specific needs, especially if they’re currently in a weakened state. This is especially important for elderly patients and those battling chronic conditions, as accidents can happen at any time. 

While educating them with the right medication instructions are necessary, it’s also important to remember that the patient will need someone to cook for them, dress them, and even perform daily tasks. Their homes must also be deemed as safe, clad with necessary medical equipment for better transitional home care. 

The Critical Role Of Transitional Care Management In The Modern’s Healthcare Landscape 

More often than not, hospitals deal with readmission cases that will have otherwise been avoidable. It can happen due to a variety of things, including improper medication instructions, lack of follow-up appointments, and even the wrong set of medications. It’s therefore pertinent that hospitals invest in a good transitional care management plan, as this will lead to better outcomes, prevent gaps, and overall ensure quality patient care standards. 

If you wish to invest in remote patient monitoring solutions and other services for transitional care management, Medistics Health has you covered. We offer you a patient monitoring system, which is a device that allows patient access to real-time conditions, such as glucose and blood pressure levels. Should anything go wrong, your patients can immediately seek medical help. Redefine the meaning of patient care with us—reach out today to learn more. 

Profit Calculator Assumptions: 40% of total Medicare patients enrolling is based on (i) Medicare Chart Book’s data showing that ~68% of medicare patients qualify for CCM (2 or more chronic conditions), and (ii) that ~40% of eligible patients will enroll.

For typical providers, $46.67 of net profit per patient per month is based on a Medicare reimbursement per patient per month (national average) for various care management CPT codes.

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