Transitional Care Management

Needs Statement

Transitional Care Management (TCM) services play a crucial role in facilitating a smooth transition for patients moving from inpatient to community settings. Following a hospitalization or stay in an inpatient facility like a skilled nursing facility, patients often confront medical crises, receive new diagnoses, or undergo changes in medication therapy. The responsibility of overseeing this transitional phase frequently falls on family physicians. Managing the transitional care of our aging population demands a blend of care, precision, and effective teamwork. Ensuring a seamless handover of care back to the primary care team becomes paramount when a hospitalized patient is ready to return home. Centers for Medicare & Medicaid Services (CMS) has set a goal of having 100% of Traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries in these types of accountable care relationships by 2030.

Educational Objectives

At the conclusion of the session, the participants should be able to:

• Define Transitional Care Management (TCM) and review its requirements.
• Describe the elements of both non-face-to-face and face-to-face contacts.
• Describe how to document a Transitional Care Management Encounter.
• Identify the process of coding for a Transitional Care Management Encounter in the Electronic Health Record.
• Apply collaborative strategies within the Clinically Integrated Network, physician, and APP team to ensure a seamless transition of care.

Target Audience

Activity Evaluation

Evaluation by questionnaire will address program content, presentation, and possible bias.

Educational Methods

• Lectures
• Other

Accreditation/Credit Designation

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Baylor College of Medicine and Texas Health Network CIN. Baylor College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Term of Approval

February 1, 2024 through February 28, 2026. Original release date: February 1, 2024.

Disclosure Policy

Baylor College of Medicine (BCM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians. BCM is committed to sponsoring CE activities that are scientifically based, accurate, current, and objectively presented.

In accordance with the ACCME Standards for Commercial Support, BCM has implemented a mechanism requiring everyone in a position to control the content of an educational activity (i.e., directors, planning committee members, faculty) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships at the time of the activity or within 24 months prior.

In addition, BCM has requested activity faculty/presenters to disclose to participants any unlabeled use or investigational use of pharmaceutical/device products; to use scientific or generic names (not trade names) in referring to products; and, if necessary to use a trade name, to use the names of similar products or those within a class. Faculty/presenters have also been requested to adhere to the ACCME's validation of clinical content statements.

BCM does not view the existence of financial relationships with commercial interests as implying bias or decreasing the value of a presentation. It is up to participants to determine whether the relationships influence the activity faculty with regard to exposition or conclusions. If at any time during this activity you feel that there has been commercial/promotional bias, notify the Activity Director or Activity Coordinator. Please answer the questions about balance and objectivity in the activity evaluation candidly.

All of the relevant financial relationships listed for these individuals have been mitigated.