Dementia and Care Transitions: Do Transition Care Management Codes Make a Difference?

TitleDementia and Care Transitions: Do Transition Care Management Codes Make a Difference?
Publication TypeJournal Article
Year of Publication2022
AuthorsHoeksema, M, Carnahan, JL
Keywordscare transitions, Dementia

For older adults living with dementia, care transitions from acute or subacute care back to their community can have adverse outcomes such as hospital readmissions, medication errors, or even permanent nursing home placement. To address these adverse outcomes, Transition Care Management (TCM) codes were introduced by the Centers for Medicare and Medicaid Services (CMS) in October 2012. The efficacy of TCM codes has not been examined in the population of persons living with dementia. Thus, this study examines the effect of TCM codes on hospital readmission rates and hypothesizes that TCM codes are effective in decreasing readmission rates after care transitions for persons living with dementia.

After an extensive literature review, we identified the Bynum Standard method for identifying persons living with dementia. We used a linked dataset from the Health and Retirement Study (HRS) and CMS claims to identify persons living with dementia with a hospital discharge between 2015 and 2018.

Our initial search has identified a cohort of 4,282 persons living with dementia.
1,584 (37%) are male and 2,698 (63%) are female. 3,433 are White, 656 are Black, 126 are Hispanic, 14 are Native American, 4 are Asian, and 49 are either of another race or did not report their race.

Conclusion and Potential Impact:
Thus far, we have identified a cohort of persons living with dementia from HRS-CMS linked data but have yet to identify who have had the TCM codes used by their provider. In the future, we will examine the effect that TCM codes have on hospital readmission rates within the studied population. Not only will this study determine if these billing codes provide effective care, but it can also tell us if it aids historically underserved groups.

Citation Key13120