JPMC to provide Transitional Care Management Services

Jane Phillips Medical Center is again responding to the needs of its patients by opening a Transitional Care Department. 

“Medicare recognized that limited access to primary care physicians immediately following discharge is a major reason for hospital readmissions,” stated JPMC Director of Quality Diane Garrett, RN. 

In 2013, Medicare published regulations to allow reimbursement to hospitals and physicians for Transitional Care Management Services (TCM). TCM includes those services required during the patient’s transition to the community setting during the thirty days following a hospital discharge.  JPMC health care professionals accept responsibility for the care of the qualified patients to prevent gaps in medical supervision for those the thirty days.

“Our goal is to provide education and referrals to appropriate community resources in order to improve health outcomes for the patients, and reduce hospital readmissions for the same or similar conditions during that timeframe,” Garrett said.

Beginning in June, the department will see patients by appointment between the hours of 8 a.m. and 5 p.m. Monday through Friday.  The Transitional Care department will see select patients after discharge from one of the following hospital settings:

  • Inpatient acute care;
  • Inpatient psychiatric unit or hospital;
  • Long Term Care Hospital (LTAC);
  • Skilled Nursing Facility (or swing bed);
  • Inpatient Rehab, or
  • Outpatient Observation.

To qualify for these services, the patient must not only be discharged from one of the above settings, but the patient must be discharged to a community setting, such as:

  • Personal home;
  • Home of family or friend;
  • A rest home (nursing home, long term care); or
  • Assisted living.

TCM services are provided under the direct or indirect supervision of a physician or a non-physician practitioner (NPP) such as a Clinical Nurse Specialist, Nurse Practitioner or Physician Assistant.  JPMC's current Licensed Clinical Staff (Social Worker, RN, Pharmacist, Dietitian, etc.) will work closely with the physician or NPP to furnish most of the services needed such as: 

Review discharge information, focusing on medication reconciliation and medication education;

Review need for follow-up on pending diagnostic tests and treatment;

Interact with other healthcare professionals who will assume or reassume care of the clinical problems;

Establish or re-establish referrals and arrange for needed community resources;

Assist in scheduling required follow-up with community providers and services;

Identify available community and health resources and communicate with those entities;

Provide education to the patient, family, guardian, and/or caregiver to support self-management, independent living, and activities of daily living; and

Assess and support treatment regimen adherence and medication management.

During the 30-day transitional period, a physician or NPP will have at least one face-to-face visit by the seventh day, but no later than the fourteenth business day post discharge.  The timing of this face-to-face visit is determined by the complexity of the patient’s condition at discharge, and the risk of significant complications associated with their clinical problems or management options.

“Our patients often get discharged and cannot secure a follow-up appointment with a physician or NPP for three to four weeks after discharge.  For those complex patients, this timeframe lends itself to readmissions within the thirty days immediately following a hospitalization,” stated Garrett.

JPMC Chief Operating Officer Mike A. Moore said hospital lengths-of-stay are getting shorter, so patients need a complete understanding of the discharge instructions, particularly regarding medications and other follow-up care. 

“These patients are part of our community and JPMC is committed to meeting their healthcare needs to the best of our ability. We believe that our responsibility for their health care goes beyond our hospital walls. The Transitional Care Department will help us fulfill that commitment.”

  Moore said the new service will allow JPMC to closely monitor patients’ progress immediately after discharge.  In doing so, there will be an opportunity to further educate, reinforce previous education, and work with patients and their families to determine the most appropriate services necessary to achieve and maintain their optimal level of wellness.  


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