Transitional Care Management:  Patients are moving; Are you moving with them?


Self-paced – recommended timeline approximately 8 weeks




CMS has long embraced the idea of the safe transfer of patients from one level of care to another with coordination and collaboration key to that movement.  The American Care Management Association defines care transition as “a process of transferring a patient from one care setting or level of care to another, such as from hospital to home, hospital to skilled nursing facility or taking steps in the home to avoid the need for care in another setting.  These transitions are particularly vulnerable points in the healthcare continuum”.  Transitional care identifies those processes that prevent adverse events and promote continuity of care for the patient and family.  According to the Centers for Medicare and Medicaid (CMS), the costs related to poorly managed care transitions of Medicare patients from acute care alone is $26 billion per year (2016 data). 

This course is designed to provide health professionals, such as nurses, primary care clinical staff and alike, with the knowledge, skills, and abilities to provide Transitional Care Management (TCM) services to effectively reduce readmissions and to prevent adverse events that may result during transition, such as medication errors or treatment delays.  The elements of Transitional Care Management will be outlined in an easy to understand format and will provide background material for the understanding of TCM.

Delivery Format:

The course is divided into four (4) modules. Each module may take up to two (2) weeks. The development of understanding the process to provide TCM occurs when knowledge and practice are combined. This Transitional Care Management Course will put knowledge into practice as participants are immersed in this self-paced course with interactive discussion boards and optional monthly check-ins with the instructors. The education will be delivered in a virtual environment using a combination of pre-recorded didactic presentations, asynchronous discussion threads, and a virtual meeting space for a live monthly discussion with the instructors.


Module 1 – Why Transitional Care Management?
– Background of Care Coordination and TCM
– Purpose of Transitional Care Management
– Movement of patients between locations

Module 2 – Who should be involved in Transitional Care Management?

– Components of Transitional Care Management
– Who are the right people and how are they coordinated?
– How does the PCP interact with the Hospitalist, Consultants, and other care givers?

Module 3 – How do you implement TCM?

– How do you make it work?
– What reports and contacts do you need?
– Are you thinking outside the box related to community resources?

Module 4 – How do you integrate Transitional Care and Chronic Care?

– Fitting the pieces together.
– Creating continuity of care for the patient.
– The elements in place to bill for the service.


At the completion of this course, the participant will be able to:
– Understand the background and intent of TCM.
– Explain care management for TCM.
– Understand the Primary Care Provider and registered nurse’s role in care coordination.
– Identify and explain the components of TCM.
– Understand the combination of TCM and CCM for enhanced patient outcomes and improved quality of life.
– Recognize importance of monitoring, evaluating, and revising the plan of care.
– Explain the rules and regulations regarding TCM reimbursement.
– Discuss billing codes and supplemental material to enable billing for TCM.

Continuing Education Credit Calculations:

Module 1: Objectives 01-02/Recommend 2 wks. per module/Asynchronous Discussion & Clinical Practice (3 Hours); Recorded Lecture (50 Minutes)/1 hr.

Module 2: Objectives 02-04/Recommend 2 wks. per module/Asynchronous Discussion & Clinical Practice (3 Hours); Recorded Lecture (50 Minutes)/1 hr.

Module 3: Objectives 05-06/Recommend 2 wks. per module/Asynchronous Discussion & Clinical Practice (3 Hours); Recorded Lecture (50 Minutes)/1 hr.

Module 4: Objectives 07-08/Recommend 2 wks. per module/Asynchronous Discussion & Clinical Practice (3 Hours); Recorded Lecture (50 Minutes)/1 hr.

Total: 8 hrs

Continuing Education Credit Information:

HealthTech Management Services D/B/A HealthTech is a Provider approved by the California Board of Registered Nursing. Provider Number CEP8769 for 8.0 contact hours. Participant must complete all course work – no partial credit will be given. A certificate of completion will be provided by HealthTech within 30 days of successful completion of the course.

Refund / Cancellation Policy:

Cancellations received in writing prior to the start of the course will be refunded, less $50.00 administrative expense. Registration fees may be transferred to another individual prior to the start of the educational offering.  Individuals who enroll in an online educational course and who open any module content will not be eligible for refunds.


Faith M Jones, MSN, RN, NEA-BC

Director of Care Coordination and Lean Consulting, HealthTech

Faith Jones began her healthcare career in the US Navy over 30 years ago. She has worked in a variety of roles in clinical practice, education, management, administration, consulting, and healthcare compliance. Her knowledge and experience span various settings, from ambulatory to inpatient to post-acute. In her leadership roles she has been responsible for operational leadership for all clinical functions including multiple nursing specialties, pharmacy, laboratory, imaging, nutrition, therapies, as well as administrative functions related to quality management, case management, medical staff credentialing, staff education, and corporate compliance. She currently implements care coordination programs focusing on the Medicare population and teaches care coordination concepts nationally. She also holds a Green Belt in Healthcare and is a Certified Lean Instructor.

Cynthia A Christenson, MSN, RN, CPHRM, CPHQ

Christenson Consulting, LLC, Owner & Independent Contractor for HealthTech

Ms. Christenson is a consultant for HealthTech.  She has been a nurse for over forty years and has rich experience in the fields of Risk Management and Healthcare Quality as well as serving as the Chief Clinical/Nursing Officer for two organizations.  She has been a member of the National Association of Healthcare Quality and the American Society for Healthcare Risk Management for many years.  She has been actively involved in preparing providers for legal defense in medical malpractice.  She has also been active in the accountable care organization arena training Clinical Care Coordinators and Primary Care Providers to meet the CMS ACO requirements.  She currently works with HealthTech assisting with the Care Coordination program.  She continues to grow and learn and is keenly interested in the emerging field of telehealth.


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