Transitional Care Management: Things You Need To Know

Transitional care management is a crucial part of the healthcare process, as transitions are often the riskiest and most costly part of the entire care experience. Whether moving a member from the hospital to a rehab facility or from hospital to home, all transitions require careful planning and coordination from all involved care team members.


To ensure that transitions between settings occur smoothly and without jeopardizing a member’s health, protocols for Transitional Care Management have been developed to guide the process. Advanced software applications have also been developed to support care transitions with enhanced coordination and communication between care teams.


Continue reading to learn more about transitional care management services and the technology emerging to support this delicate stage in the healthcare process.


What Is Transitional Care Management?


The essence of transitional care management is simply a series of processes to more easily, efficiently, and safely move members from one healthcare setting to another depending on their specific needs. For example, members could be moving from the hospital to a skilled nursing facility, rehabilitation center, or to home.


These transitions are extremely critical to the patient. A poorly conducted transition could negatively impact the patient’s health , or even send them back to the hospital. Unfortunately, transitions are also often where care breaks down.


In some instances, once a patient’s transition to home has occurred, the patient might not receive adequate levels of after care services which results in relapsing and/or needing to be readmitted. Without someone taking control of the patient’s care immediately upon transition, important appointments might not be scheduled, resulting in gaps in care and leading to negative health outcomes, possible readmission and lower quality and satisfaction.


What Are the Components of Transitional Care Management?


Transitional care management is comprised of three main elements: teamwork, workflow, and continuity. These three components must seamlessly work together to keep members moving forwards in their plan of care, not backwards.




Using Incedo gives the entire care team access to the member’s care plan before, during, and after the transition period. It is essential for all stakeholders in a patient’s care to collaborate and to remain informed in order for the member to receive the best care possible.




Incedo provides an automated workflow to ensure that the necessary contacts are happening within the time frame that they need to be. The transition period can be time-sensitive, so keeping on schedule is essential.




While the patient transitions from one setting and team to another, Incedo allows the primary care team to stay present and provide continuity of care.


What Are the Benefits of Transitional Care Management?


While transition management exists for the sake of the member’s health and safety, providers are not without benefit. Members and providers both benefit from transitional care management.


Improved Outcomes


For members, receiving transitional care management means improved outcomes. There are significantly fewer readmissions when transitional care is properly managed.


Increased Satisfaction


Members feel safer when receiving transitional care. Knowing their care team is working to accurately address their care needs and keep them at home leaves members feeling satisfied with the overall care.




By reducing readmissions, both members and providers can save. Fewer hospital or clinic visits saves money in the long-term for both parties as well.


How Care Management Software Solves Care Transition Challenges


Besides producing benefits for providers and members, care management software like Incedo supplies concrete solutions to healthcare transition challenges.


Keep Members on the Care Panel


As the primary care team is retained throughout the transition, Incedo keeps each care team member fully informed on each member. Incedo prevents members from disappearing from primary care teams’ lists.


Prevent Transition-Related Mistakes


Many healthcare-related mistakes occur during these transitions from one setting to another. Therefore, it is absolutely crucial to have a tool like Incedo to guide the process. Regardless of setting, Incedo will track members and efficiently allow the care manager to oversee the entire process.


Control Spending & Reduce Costs


Care management tools一 like Incedo一 also help care managers control costs by not overpaying for recovery situations that the member doesn’t need. For example, if the member is capable of caring for themselves, but is bound for a nursing facility to recover, then the manager can move to transition the member back home instead with some support services. transition to home is likely better for the patient physically and mentally and less costly as well relative to a rehab or nursing facility.


What Does the Future of Transitional Care Look Like?


The future of transitional care is shifting towards home-based care rather than facility based services. Remote patient monitoring devices and telehealth solutions are changing the landscape of possibility for transitional care. 


Home is less costly, safer, and more comfortable for most members, but how can care management teams continue to provide active care for members at home?


Incedo provides the framework for care teams to reach beyond basic healthcare necessities like medication and equipment. They can guarantee their members receive medically appropriate meals, transportation, and other routine assistance. The capability of Incedo to incorporate community-based services providers into the care management system truly sets it apart.


Incedo: Advancing What’s Possible


Incedo ensures real people continue to be the focus of transitional care. The members are the priority, and Incedo aims to improve their outcomes, reduce costs, and increase satisfaction.


Careful management of the transition from one healthcare setting to another, such as hospital to home, is advantageous for providers and members alike. The continuation of person-centered care via a fully integrated platform like Incedo guarantees the highest quality possible throughout the healthcare process.



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