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Transitional Care Management

The next level of transitional care management is being driven by AI/ML digital health with an emphasis on home care.

The readmission and ED visit rates within 30 days of discharge have been a standard in quality care measurement for decades. And while programs to reduce rates have been partially successful, the numbers confirm that more can be done:

  • Approximately 18% of Medicare patients are readmitted to the hospital within 30 days of discharge.

  • On average, 26% of Medicare patients visit the ED within 30 days of discharge.

Transitional care management (TCM) programs are meant to assist patients following a hospital discharge, typically with a care plan that involves medication management, diet, therapy, follow-up visits with providers and specialists, and educating patients with post-hospital care instructions and warning signs of a worsening condition.


Further, for the vast majority of these patients, 87% of TCM is delivered in the doctor’s office, while only 2% occurs in the home setting. And, most TCM programs rely primarily on manual processes (i.e., costly).

Turning to technology, many health plans and providers are beginning to automate TCM strategies through AI/ML and digital technologies to provide more effective and efficient post-hospital care in the home. Also, there were many positive lessons learned regarding the effectiveness of home care and telemedicine that have shifted the traditional delivery care model.

Engaging TCM patients with digital health outreach (text messages, automated calls, and email) are effective modes of communication that can augment face-to-face interactions with the care team. Utilizing AI/ML can further personalize patient communications and identify high-risk and rising-risk patients based on their electronic health records, health assessments, and self-reported information.


Collecting data from mobile and remote monitoring devices and utilizing AI/ML algorithms can provide opportunities for real-time alerting and actionable insights for the family, caregivers, and the care team. Digital tools and personalized communications can ensure patients are engaged and well-educated about their condition and care plan while still feeling connected and supported by their care team.

For post-hospital transitional care, do you think you would prefer your care provided in the home or your doctor's office?


Learn more ➡️ https://www.forbes.com/sites/forbesbusinesscouncil/2023/02/23/how-ai-digital-health-and-home-based-services-can-help-prevent-hospital-readmission/?sh=57bc089f49ec

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