Abstract
Transitional Care Management (TCM) refers to the patient’s transition from hospital discharge to continued care in the community. This study will conduct a cost-benefit analysis (CBA) to evaluate the costs and benefits of the TCM program, analyzing its benefit-to-risk ratio. The benefits and objectives of TCM in a hospital setting include reducing patient readmissions, improving the quality of care outside the hospital, ensuring continuity of care, and promoting long-term health for discharged patients (Elsener et al., 2023). The CBA will help determine the cost-effectiveness of TCM by identifying its anticipated costs over five years and comparing them with the projected benefits, aiding in making informed decisions (Elsener et al., 2023). Keywords: Transitional Care Management, Cost-Benefit Analysis, Continuity of Care, Readmissions, Centers for Medicare and Medicaid Services Focus of Stakeholders for a Cost-Benefit Analysis Identifying stakeholders involved in TCM from a hospital setting is crucial. Key stakeholders include patients and their caregivers and the hospital discharging the patient. External stakeholders encompass pharmacists, transitional care center management, payors, and community service agencies. The hospital and stakeholders aim to assess how TCM implementation will benefit patients upon discharge and reduce readmissions against the program’s costs over five years. Patients discharged under TCM will have designated caregivers or facilities ensuring seamless care and treatment continuity. Once in the community, external medical professionals will oversee patients to bridge the gap from inpatient to outpatient services. Additionally, hospitals adopting TCM can benefit financially from the Centers for Medicare and Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP), which rewards hospitals that reduce readmissions within 30 days of discharge (CMS, 2021). Value Proposition for Change Management Initiating change in healthcare organizations often presents challenges that necessitate systematic strategies for smooth transitions. Change management is essential for TCM implementation as it is a new concept for healthcare organizations, providers, patients, and staff. Effective change management requires administrative, financial, provider support, and team collaboration. It ensures a smooth transition for patients, caregivers, team members, and healthcare providers during TCM implementation. Through community partnerships, change management in TCM will highlight the program’s benefits (Nathan et al., 2021). A well-managed change initiative will enhance the quality of patient care and satisfaction during hospital stays and upon discharge for both short-term and long-term care. Failure to utilize change management can result in prolonged transition times, increased long-term patient care costs, and suboptimal care, leading to higher readmission rates. Mitigated risks include lower mortality and infection rates, fewer emergency room visits, and reduced readmissions. Moreover, TCM will reduce costs by decreasing readmissions and improving financial incentives under the CMS HRRP program (Nathan et al., 2021). Strategies to Influence and Impact Changes for Quality Improvement Research indicates that poor communication and coordination significantly contribute to preventable hospital admissions and readmissions. Hospitals without TCM models often experience higher readmission rates, mortality rates, infection rates, and long-term illnesses due to inadequate patient coordination upon discharge. Lack of TCM also indicates insufficient patient education, self-care, family involvement, and communication with external caregivers (Racheal & Shen, 2023). The success of TCM requires strong leadership and support. Active leaders provide oversight and direction, ensuring strategic momentum and accountability during TCM implementation. Key strategies for quality improvement under the TCM model include ample internal and external communication and coordination led by strong leadership. Follow-up care within 14 days of discharge is crucial to ensure proper patient care. Additionally, creating a culture of safety and continuous improvement is vital when implementing TCM (Hughes, 2008). Cost-Benefit Analysis and Assumptions A CBA is necessary to project the costs associated with implementing a TCM program. As TCM is a service-based care model, predicting the return on investment (ROI) can be challenging. Research highlights the immediate benefits and potential cost savings of TCM, such as fewer readmissions within 30 days of discharge, higher patient satisfaction, better communication, and improved continuity of care. The first-year cost of initiating TCM is estimated at $774,688. This includes leasing 1,000 square feet of clinical and office space, staffing four full-time Certified Family Nurse Practitioners (CFNPs), hiring non-clinical staf
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