Prioritizing Patients for Transition of Care Management Visits

In the Fall of 2019, I wrote a blog around overcoming transition of care management visit challenges. One of the challenges that I outlined was the physician is often not notified, or not notified in a timely manner, that their patient was discharged from the hospital or skilled nursing facility. I received messages from providers across the country, and many of the providers participate in a Health Information Exchange (HIE), but due to the limited bandwidth, are having a difficult getting to all their patients. I’d like to point out that not all patients will likely need a TCM visit, and it may be sufficient to check in with the patient telephonically, without bringing them in for an office visit. Honestly, I have never seen a practice complete 100% of TCMs, and in fact, we encourage practices to get to the 70% threshold. Our data shows that while TCMs are extremely effective in reducing readmissions and decreasing overall costs of care, prioritizing patients for the TCM is critical in reducing practice burnout and targeting the highest-risk patients to maximize ROI. So… who should you prioritize for a TCM?

  1. Skilled Nursing Facility (SNF) Patients: One in five Medicare beneficiaries is readmitted within 30 days, while one in four patients discharged from SNF to home are readmitted. A higher comorbidity index, higher age, and increased risk of medication errors during the transition may account for the higher readmission rate. One of the best ways to mitigate this risk is through a transition care visit[1]; and phone calls at regular intervals, especially immediately within two days[2] of discharge as especially helpful in reducing readmissions.
  2. Polypharmacy: 26% of readmissions are potentially preventable and medication-related.[3] There are 3 major categories of medication issues that account for readmissions: nonadherence, untreated condition for which medication is indicated, the dose was either too high or too low. Patients with multiple medications will have a higher chance of medication discrepancies and medication errors, and the best way to prevent these discrepancies is through a medication reconciliation and patient follow-up immediately after a transition occurs. Innovative practices have partnered with pharmacists to complete the medication reconciliation post-discharge.
  3. Multiple chronic conditions: Patients with multiple chronic conditions are at risk for readmissions. In fact, patients with 5 or more clinical conditions have been found to have the highest risk of readmission.[4] Practices may want to target these patients, but specifically, patients with primary diagnoses of CHF, COPD, chronic renal disease, and diabetes may benefit from a TCM due to their high readmission rates.[5]
  4. Patients with Social Determinates of Health and Behavioral Health Issues: If you open reference from HCUP, you will notice that patients with social determinates of health and behavioral health issues are most likely to be readmitted within 7 days. These diagnoses include, but certainly not limited to schizophrenia and other psychotic disorders and alcohol-related disorders. MedPac also found that low-income Medicare patients tended to have higher readmission rates because of individual effects, neighborhood effects, or both.[6] While a TCM may be helpful to reduce the immediate readmission, practices may consider referring these patients to community resources and/or behavioral health specialists, as well as enrolling them in a care management program to impact the 180-day readmission rate. 
  5. High-Risk Patients: Patients that have been admitted multiple times throughout the year may have multiple chronic conditions, behavioral health issues, and multiple medications. These patients will typically consume a disproportionate share of resources and it is necessary to target these patients for additional interventions, starting with a transition of care visit.

As you probably already know, many of the categories above will overlap. Cohorting functionality of a performance management /care management system can significantly simplify efforts in identifying patients that would benefit from a transition of care visit by flagging those patients in your actionable lists that are directly connected to the HIE. Once your practice has developed effective workflows for patient identification and outreach, it is always important to track whether your TCM initiatives are effective at reducing the 30, 90, and 180-day readmission rates.


[1] https://www.jamda.com/article/S1525-8610(15)00807-5/fulltext

[2] https://www.jamda.com/article/S1525-8610(19)30162-8/fulltext

[3] https://www.japha.org/article/S1544-3191(17)30778-1/pdf

[4] https://pubmed.ncbi.nlm.nih.gov/28863719/#:~:text=The%20margin%20declined%20into%20substantial,%24865%20per%20admission%20in%202015.

[5] https://www.hcup-us.ahrq.gov/reports/statbriefs/sb230-7-Day-Versus-30-Day-Readmissions.jsp

[6] http://www.medpac.gov/docs/default-source/reports/jun18_ch1_medpacreport_sec.pdf

Maria Nikol

About the Author


Maria Nikol

Maria Nikol is a senior business consultant with 10 years of experience in healthcare operations and healthcare strategy. Her specialization includes process improvement and the application of emerging models of healthcare delivery such as Patient-Centered Medical Homes and Accountable Care Organizations. She holds a Master of Jurisprudence in Health Law from Widener University and a Bachelor of Science in Pharmaceutical Marketing and Management from the University of the Sciences in Philadelphia.

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