mTCM Pilot Program

Intensive Follow-up Services Address Patients’ Clinical & Social Needs

Watertown, New York, March 23, 2021– Heading home after a stay in the hospital or emergency department can cause a patient to feel anxious, isolated, and uncertain. Patients may not feel confident about which medications to take, which providers to follow up with, or if other tests are needed. Without intensive support, patients’ issues may recur, leading to another hospital or emergency department visit. A new program is being piloted locally to assist Medicaid patients with this transition from hospital to home.

The pilot program is called mTCM, which stands for Medicaid Transitional Care Management. It is being launched April 1, 2021 by North Country Initiative (NCI)—the region’s clinically-integrated network—and the North Country Independent Practice Association (NCIPA), a group of North Country Initiative primary care partners who work together in jointly-contracted value-based arrangements with insurers. The roughly 9-month-long mTCM pilot is modeled after a similar, nationally reimbursable service for Medicare patients, in which primary care teams review patients’ hospital discharge information, have an interactive contact (often, a phone call) with the patient within two days after discharge, conduct medication reconciliation and other non-face-to-face services, and have a face-to-face visit with the patient within one to two weeks after discharge. These proactive measures help to keep the patient on the right track and avoid unnecessary hospital readmission or emergency department visits. Locally, this service has resulted in decreased 90-day readmissions and a 57% decrease in cost of care for Medicare patients. While transitional care management has seen great success in the region for Medicare patients, unfortunately Managed Medicaid does not reimburse for a parallel service.

“We are excited to expand this successful post-hospitalization program to the Medicaid population to provide additional support and services after an emergency department visit or hospital stay, a time that can be scary and uncertain for patients recovering from an illness or injury at home,” explains Steven Lyndaker, MD, Medical Director for NCI and Fort Drum Regional Health Planning Organization and Partner at Lowville Medical Associates. “I am confident that increased care management and timely intervention for our patients will result in positive outcomes and reduced utilization of expensive hospital care through the support and follow up we provide through TCM.”

The mTCM services are structured similarly to those provided for Medicare patients, with two significant differences: unlike Medicare, the mTCM pilot will reimburse for these services following an emergency department discharge, and it incorporates a standardized screening to identify patients’ social needs. This provides an opportunity to evaluate conditions in the patient’s social environment that may be contributing to the illness or injury that led to the need for hospitalization.

“Social determinants of health (SDH) are factors that patients may face outside of the traditional healthcare realm, such as housing, transportation, and others,” states Amanda Rydberg, RPA-C, Associate Medical Director at River Hospital. “Knowing that these types of needs can significantly impact a patient’s health and well-being, we are excited to incorporate SDH into the mTCM program. By incorporating a standardized tool that screens for these factors, we are weaving into our practice workflow a way to uncover and identify social needs of our Medicaid patients who have just experienced an inpatient or emergency department discharge. This will lend critical insight into the prevalence of social needs and will assist patients through referrals to appropriate SDH services in our community.”

Through mTCM, enhanced payments will be made available to North Country Independent Practice Association partners who incorporate SDH screening into their workflows, and who complete all required elements of the mTCM service with patients. The program’s outcomes and results, including its benefit to patients and impact on improved quality and reduced cost of care, will be measured to demonstrate the value of incorporating this service into the Managed Medicaid payment structure.