CSMS-IPA May 2022 Newsletter


Transitional Care Management (TCM)

Transitional Care Management (TCM), also known as Transitions of Care (TOC) is designed to bridge the gap between inpatient discharge, PCP follow-up and patient self-care at home.  A good TCM process lowers the risk of readmissions, reduces post discharge mortality, avoids medication errors, improves patient satisfaction and outcomes and lowers the costs of care. TCM is a key factor in value- based payment practice success.

Getting Help with TCM

  • If you need assistance developing workflows for TCMs please reach out to your practice resource.
  • CSMS-IPA notifies practices of admissions for certain payers via email. Please check for these emails and initiate your TCM workflow when you receive one.

CSMS- IPA Network Performance – How Are We Doing on Transitional Care?

During 2021, in a sample of 481 discharges of Medicare Advantage patients only 27% received full TCM services. However, 69% of these patients did have a visit in the 30 days following discharge. With focused effort, we can do better.

Emergency Department Visits – New HEDIS Measure

What is the measure?
The percentage of emergency department (ED) visits between January 1 and December 24 of the measurement year for members 18 years and older who have multiple high-risk chronic conditions and who had a follow-up service within seven days of the ED visit (eight days total).

Eligible members:
Members who are 18 years or older on the date of the ED visit:

  • and have two or more chronic conditions diagnosed prior to the ED visit.
  • and visited the ED on or between January 1 and December 24 of the measurement year.
Practical implications of the new HEDIS measure for practices:
  • Educate patients to call you first before going to the ED, except in the case of life-threatening emergencies.
  • Use population health tools alerts to identify patients who have been to the ED, then contact these patients promptly to schedule a visit. 
  • Use IPA Population health reports and tools to identify chronically ill patients who are regularly using the ER for care - engage them in regular visits and preventive care to avoid the ED.
CSMS-IPA Resources for Transitional Care Management

CSMS-IPA Care Transitions
Toolkit available on the CSMS-IPA website (CSMS-IPA sign on required to access)
  • Contains practical tools, scripts and checklists for post discharge calls, visits, readmission reduction and patient handouts.
Other Resources – Available on the CSMS-IPA website (no password access required)


The Connecticut State Medical Society - IPA (CSMS-IPA) is the largest and only statewide IPA in Connecticut and one of the largest in the nation. The CSMS-IPA is comprised of approximately 7,000 physician members. The CSMS-IPA is governed by a 27-member physician Board of Directors.



Corporate Office
127 Washington Avenue
East Building, Lower Level
North Haven, CT 06473
Phone: (203) 562-7228
Fax: (203) 624-6665

Operations Office
1 Corporate Drive, Suite 315
Shelton, CT 06484
Phone (203) 225-1291
Fax (203) 925-2652
© 2024, CSMS-IPA, Inc