Transitional Care Management

Transitional Care Management - Toolshero

Transitional Care Management: in this article you will find a practical explanation of Transitional Care Management (TCM). It covers what TCM is, when it is used, how it is used and by whom and what its purpose is. It also provides the CPT codes for TCM and tips on how to best provide Transitional Care Management. After reading this article, you will understand the basics of this method of care that the health care field implements for patients who need observation after leaving the clinic or the medical process they were in.

The health area, as it advances with the inventions of science and technology, also advances with the care to human rights and the wellbeing. Nowadays, the importance of protecting, attending to, caring for and accompanying patients who are critically ill or in need of medical treatment has made clinical companies more aware of the need to create processes such as Transitional Care Management.

What is Transitional Care Management TCM?

TCM is a method used by hospitals and other healthcare facilities who look after the well-being of a patient when he or she is finishing the medical process in a hospital and needs a transition from medical care. This transition is generally from a hospital setting to a community setting.

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Transitional Care Management is the management of care services during the period after the patient’s stay in a complex hospital setting. With this approach, it is ensured that the patient can transition out of the hospital, either at home or in another home.

With the proper care and quality of care provided to the patient, the patient will not have to return to a clinic or even relapse due to lack of care or medical attention. This is why this transition method is important to implement after a crisis, as its goal is to recover the patient without relapse and to achieve a successful recovery.

Professionals involved in TCM

Health professionals who can provide and bill for medical services

  • Physician (any speciality)
  • Clinical Nurse Specialist (CNS)
  • Nurse Practitioner (NP)
  • Physician assistant (PA)

How and when is Transitional Care Management (TCM) used?

This clinical process is not used in all medical cases, but only in exceptional cases where the patient needs the extra attention and care when coming out of a difficult health process. This provision of care is for a period of 30 days, 29 days from the day of discharge. The health care settings that offer this transition (TCM) are, among others:

  • Inpatient acute care hospital
  • Inpatient psychiatric hospital
  • Long-term care hospital
  • Skilled nursing facility
  • Inpatient rehabilitation centre
  • Hospital outpatient observation or partial hospitalisation
  • Partial hospitalisation in a Community Mental Health Centre

Illnesses that commonly require TCM:

  • Dementia
  • Heart disease
  • COPD
  • Diabetes
  • Chronic diseases
  • Among others

What is the purpose of transitional care management?

In the 29 days that the patient is out of the clinic, they will receive care (TCM). Transitional Care Management is divided into categories in which the patient can be monitored and followed up after discharge.

1. Interactive contact

Interactive contact is used after the patient has been discharged and is at home. It is necessary that in the days following discharge, the patient is followed up by the clinic’s employees. This follow-up can take the form of emails, phone calls and home visits (face-to-face).

2. Non-face-to-face services

If the patient’s caregiver (clinic) sees that it is not necessary to have interactive contact with the patient, as their situation is out of risk, self-care services and instructions for the patient and their companion can be provided (person who is watching over the patient’s recovery). These instructions are usually given in the form of guidelines on the self-care processes to be followed during the 29 days of recovery.

3. Face-to-face visits

The health care provider should regularly schedule some face-to-face visits with the patient to review their health status and follow up on their recovery. This should occur before or during the patient’s visit. Consider the following:

  • Medication management and review
  • Medical history review?
  • Review whether further testing is appropriate
  • Discuss whether or not to continue medical treatment
  • Educate the patient, friends and family about self-care at home

Tips on how to best provide Transitional Care Management

It is important to have a plan and follow-up moments for the patient in his transition phase. The care he has at home will lead to a successful recovery.

With this in mind, it is very important to note that the health entity has the capacity and resources to meet this need during the 29 days. If this is done with the necessary factors, the patient will be able to cope with the situation in the best possible way.

The following tips enables caretakers to better provide the necessary support:

  • Delegate roles to the people who will be looking after the patient in the days following discharge.
  • Schedule times for calls, home checks and so on so that both the professional in charge and the patient know which day they have control-monitoring of their health and well-being
  • Keep a record in software applications or other formats which contains the clinical history about the process that the patient has in the following days. Also keep a record of old or new medications taken during recovery
  • In the case of self-care instructions, make sure that the patient and their caregiver have easily understood what they need to do to make a speedy recovery. Use resources such as forms or files where they can write down and keep their own records if necessary
  • Assess whether further testing is needed in the 29 working days to see progress or if more symptoms have occurred. This will make it much easier to implement TCM.
  • Document visits or follow-up of the TCM patient:
  • Date the beneficiary was discharged
  • Date of interactive contact with the beneficiary and/or caregiver
  • Date of face-to-face visit
  • Complexity of medical decision making (moderate or high)

Transitional Care Management Use of Codes

The American Medical Association (AMA) has assigned CPT codes 99495 and 99496 for reporting Transitional Care Management services.

  • CPT Code 99495: moderate medical complexity requiring a face-to-face visit within 14 days of discharge
  • CPT code 99496: high medical complexity requiring a face-to-face visit within seven days of discharge


Transitional Care Management is essential for the follow-up of chronic diseases or diseases that need medical management, as the patient may relapse and be readmitted to hospital. Transitional Care Management (TCM) aims to reduce readmissions and potentially preventable medical errors during the 30 days following discharge from the acute care setting.

It recognises the support that must be provided to patients who have experienced health difficulties and how this support must persist after discharge. This is why TCM is used as a form of community care where the patient is in the comfort of their own home and with their loved ones, without neglecting the medical care and wellbeing that is necessary for their stability.

As highlighted at the beginning, the medical field has had notable advances in the development of technology and science, but it has also advanced in being more concerned with the importance of how the subject feels about their illness and how they can provide the best wellbeing to combat their medical crises.

Thus, the patient feels accompanied by the medical management in their process, they are not alone in their illness and they have the follow-up and control they need. Healthcare providers are more committed than ever to use Transitional Care Management when a patient is discharged to follow and control the disease until recovery.

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Now It’s your turn now

What do you think? Do you think there is a need to implement Transitional Care Management for chronic patients or patients coming out of care illnesses? Have you implemented or already knew about the TCM method? Do you have anything else to add or any suggestions?

Share your experience and knowledge in the comments box below.

More information

  1. Agarwal, S. D., Barnett, M. L., Souza, J., & Landon, B. E. (2018). Adoption of Medicare’s transitional care management and chronic care management codes in primary care. Jama, 320(24), 2596-2597.
  2. Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: the transitional care model. Online J Issues Nurs, 20(3).
  3. Marcotte, L. M., Reddy, A., Zhou, L., Miller, S. C., Hudelson, C., & Liao, J. M. (2020). Trends in Utilization of Transitional Care Management in the United States. JAMA network open, 3(1), e1919571-e1919571.

How to cite this article:
Janse, B. (2021). Transitional Care Management. Retrieved [insert date] from Toolshero:

Original publication date: 09/09/2021 | Last update: 08/16/2023

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Ben Janse
Article by:

Ben Janse

Ben Janse is a young professional working at ToolsHero as Content Manager. He is also an International Business student at Rotterdam Business School where he focusses on analyzing and developing management models. Thanks to his theoretical and practical knowledge, he knows how to distinguish main- and side issues and to make the essence of each article clearly visible.


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