The Benefit- Reduce Government and Payer Spending

Transitional Care Management (TCM) is a billable service provided to address the hand-off period between a patient’s discharge from an inpatient facility up until the provider assumes responsibility of the patient, typically occuring at the 1st office or telehealth visit after hospital discharge.  The goal of TCM is to manage this gap in care to assure the patient does not decompensate leading back to a readmission. At Prime Clinical Associates, our care managers manage the TCM process preparing the patient for the first in-office visit/telehealth by: 

• Scheduling TCM appointment 
• Communication with agencies and community service providers the patient uses 
• Assessing and supporting treatment adherence, including medication management 
• Identifying available community and health resources 
• Helping the patient and family access needed care and services 
• Educating the patient, family, guardian, or caregiver to support self-management, independent living, and activities of daily living 

To aid patients in transitioning from emergency room (ER) visits and address the issue of overutilization of emergency care, Prime Clinical Associates offers Emergency Room Follow-Ups (ERFU). These follow-up visits entail E/M encounters during which the provider reassesses and evaluates the patient following their discharge from the ER. The primary objective is to educate the patient on the distinctions between ER and PCP visits while identifying any necessary services to prevent relapse and ensure continuity of care. 

 Key points about ERFU:

1. Service Initiation: ERFU is initiated after patients have been discharged from the emergency room. This strategy is a  proactive measure to ensure that patients receive appropriate follow-up care and understand their treatment plans.
2. Prevention of Relapses: One of the main objectives of ERFU is to prevent relapses or worsening of the patient's condition. This could involve monitoring the patient's progress after their emergency room visit and intervening if necessary to prevent further complications.
3. Patient Education: ERFU also involves educating patients about when it's appropriate to seek emergency room care versus visiting their PCP. This education component is essential for helping patients make informed decisions about their healthcare and ensuring that they use emergency services appropriately.

Overall, ERFU is a valuable service aimed at improving patient outcomes, reducing unnecessary emergency room visits (reducing costs), and promoting patient education in the healthcare system.