Designing Winning “Transitions of Care” Processes!Lee Radosh, MD, FAAFP

Faculty, PAFP Residency Collaborative (RPC)

Director, Family Medicine Residency

Reading Hospital of Reading Health System, Reading, PA

Lee.Radosh@readinghealth.org

October 9, 2013

DISCLOSURE

Neither I nor any immediate family member (parent, sibling, spouse or child) has a financial relationship with or interest in any commercial entity that may have a direct interest in the subject matter of this session.

Objectives

By the end of this presentation, participants will be able to: List key recent external forces related to transitional

care Identify “priority tasks” in transitional care Utilize tools and processes to augment your planning Identify new CPT codes

Agenda

Define TOC Make a cogent argument

for four main areas to “attack”

Present tools to assist Review newer CPT

codes

What is a WinningTransitions of Care Process?

One that is MEANINGFUL, to You, the practice (efficient) Patients (clinically important) Insurers (financially sound) Hospital/practice administrators (all of the

above!)

For Our Purposes, Transitional Care Is . . .

“ . . . the actions of healthcare providers designed to ensure the coordination and continuity of health care during the movement, called care transition, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs.”

Wikipedia

For a Different Time . .(But Two Minutes Please . . . )

Transitional care is also for young people Moving successfully from child to adult health

services http://www.medicalhomeinfo.org/how/care_deliv

ery/transitions.aspx AAP medical home/transitions website

http://www.pafp.com/pafpcom.aspx?id=785 PAFP / AAP partnership

A, Health care transition-planning algorithm for all youth and young adults within a medical home interaction. a For pediatric practices, transfer to adult provider; b the MCHB defines

children with special health care needs as “[t]hose who have or are at i...

American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group Pediatrics 2011;128:182-200

©2011 by American Academy of Pediatrics

A, Health care transition-planning algorithm for all youth and young adults within a medical home interaction. a For pediatric practices, transfer to adult provider; b the MCHB defines

children with special health care needs as “[t]hose who have or are at i...

American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians, Transitions Clinical Report Authoring Group Pediatrics 2011;128:182-200

©2011 by American Academy of Pediatrics

Transitions of Care

SHOW ME THE MONEY

EVIDENCE!

Ann Intern Med. 2009 Feb 3;150(3):178-87.“A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.”INTERVENTION: A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.CONCLUSION: A package of discharge services reduced hospital utilization within 30 days of discharge.

Pharmacotherapy. 2008 Apr;28(4):444-52.“Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility.”INTERVENTION: Patients were assigned to the medication reconciliation program (113 patients) or to the usual care control group (408 patients) after discharge to home from an SNF. Assignment to the medication reconciliation group or to the control group was based on provider submission of a discharge summary within 0-48 hours of discharge or more than 48 hours after discharge, respectively.CONCLUSION: Our data support the hypothesis that a formal medication reconciliation process, with its increased coordination of information between health care providers and patients, can decrease mortality after discharge from an SNF. Our findings support the role of medication reconciliation as an integral step in the transitional care process and interests of health care accrediting agencies, such as the Joint Commission, that have included medication reconciliation as an important initiative.

Multidisciplinary team approach

Clinical protocols and regional guidelines

Enhanced palliative care consultation and support

Education (of patients and caregivers)

Coaching Personal health record Community supports

Evidence-Based Care Transitions Strategies Enhanced information

transfer at discharge Follow-up care established

at discharge Improved medication

management Post-discharge plan of care Telephone follow-up Telemedicine Electronic health record

(EHR)Ventura, T et al. (2010). Improving Care Transitions and Reducing Hospital Readmissions: Establishing the Evidence for Community-Based Implementation Strategies through the Care Transitions Theme. The Remington Report, 18(1), 24; 26-30.

Which is NOT one of the programs for bundled payments for care improvement initiative by Medicare?

1. Acute care hospital stay only

2. Acute care stay + post-acute care

3. Just post-acute care

4. All care for a patient prospectively paid for a 180 day period

In the final ACO rules by Medicare, providers will have to meet how many quality metrics to qualify for performance bonuses?

1. 3

2. 33

3. 100

4. 309

What Does This Mean Now?

Here are the measures 33 quality metrics Several domains

Nice Summary of ACO Rule

http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/background/medicare-aco-summary.Par.0001.File.tmp/AAFP-Final-Medicare-ACO-Summary.pdf

Only 19 pages!

Goal

Be ready for the requirements! Kudos to the PAFP (and others) for having the

vision to prepare us all for what’s to come

Operationalize This:How to Quantify (metrics) - What To DO To Prevent Re-admissions

Have appointment made prior to discharge Medication reconciliation (by phone/in person) Discharged patient should be seen within __ days High-risk patients (“frequent flyers”)

Develop a registry of some sort Frequent contact

Maybe weekly after discharge All on the list, at least monthly

Communicate with Hospitals

Identify 1-3 main hospitals where your patients go

Communicate Develop transition plans

Other Tools to Assist?

FMDRL (Family Medicine Digital Resource Library) or fmdrl.org

Patient Name (Last, First):_______________________________________ DOB:_______________

Date/Time of Call(s) attempted but not completed with caller initials:

1)______________________________ 2)______________________________ 3)_______________________________

Message script: “Hello this is _________. I’m calling from _________as a follow up from your hospitalization. Someone from our office will try to reach you again tomorrow, but please feel free to call back today at (office number) and ask for _________.”

If unable to reach patient after three attempts, date certified letter sent with mailer initials:________________________

Date/Time call completed with caller initials:______________________________

With Discharge Instructions and Medication Reconciliation Forms in front of caller:

“Hello this is _________, may I speak with _________(patient, caregiver, or parent of minor patient)? I’m calling from _________as a follow up from your hospitalization. How you are doing today?”

“If you have your discharge instructions and medication list handy, could you go get them so we can review them together?” (If patient does not have available, proceed without them.)

If significant clinical issues arise or there are discrepancies with medications, action is required: immediate office visit, involve homecare or family, notify physician, or send to Emergency Department.

Script Patient Response Action taken “I understand you were in the hospital for___.” (See Discharge Instruction sheet, section Reason for Admission/Diagnosis and Problems)

“Is this correct?”

Yes / No. If no, explain:

“How is your condition since you got home?” Comments:

“Now that you’re home, do you have any questions about your discharge instructions?”

Yes / No. If yes, explain:

If applicable, “Have you completed or scheduled your blood work for _______?” (list LAB TESTS on discharge instruction sheet)

Yes / No. If no, explain:

If applicable, “Have you completed or scheduled your ________ ? “ (list ADDITIONAL TESTS on discharge instruction sheet)

Yes / No. If no, explain:

‘Let’s review your medications”. Then go through each one on the Medication Reconciliation form.

Confirm that if medication on the Medication reconciliation form is marked CONTINUE, that patient is taking as directed.

Note discrepancies:

Confirm that if medication on the Medication reconciliation form is marked NOT CONTINUE, that patient is not taking.

Note discrepancies:

“Are there any other medications that you are taking that are not on the list?”

List:

Do you have a scheduled appointment with your Family doctor?

Yes / No. If no, schedule. If yes, remind about date/time.

“Thank you for your time. We look forward to seeing you on (restate appointment date and time). Please bring all your medications and discharge instructions to your appointment.”

5.26.10(2)

Glass G, Roehl B: UMH Hospital f/u phone script (available at fmdrl.org)

IHI (Institute for Healthcare Improvement):http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx

Some Examples (From FHCC)

FHCC = Family Health Care Center (clinical site of our residency)

Residents used to do EMR “Chart Note” at discharge Now, Epic – “One patient, one chart”

F/u visits (if appropriate) made All most discharges get phone call (or secure

message from EMR) within 24 hrs from care manager/team nurse/physician Placed on registry?

Transition Care by FHCC Care Manager and/or Team Nurse

Receives/reviews lists (daily, monthly) of patients seen in ER and hospital discharges Currently RH only

Calls all patients within 24 hours (business day) Ensures follow-up appointments Answers questions Admittedly: low yield

Focuses upon high-utilizers (maintains registry) Communicates with physicians about their

patients (via EMR system)

Name DOB MR#Date of

D/C ER?Hosp

discharge? TRHMC?Other

(which?)Phone call

made?Date of contact Contacted by

FHCC F/U App't Made?

Date of FHCC f/u

In CM Registry prior to

d/c?Responsible

Provider

Resp prov

notified? Asthma CHF COPDBronchitis/URI/

PneumoniaOrtho/MS

Pain HA

Hyperglycemia/La

b issueDepression/

anxietyOther (list main

dx)

Was pt on FHCC service (adm only)?

Non-FHCC referrals

Action plan

Safety issues Comments

11/30/1932 5/1/2011 X X had appt 5/9/2011 Cunningham X6/19/1990 5/1/2011 X X X LM 5/2/2011 NMK Patel Pain all over Y4/11/1978 5/1/2011 X X X 5/2/2011 NMK Peterson vomiting8/17/1984 5/1/2011 X X X 5/2/2011 NMK not needed Shanmugam boil/mole change

10/19/1964 5/1/2011 X X appt tomorrow 5/2/2011 NMK 5/3/2011 Raff Diarrhea, Vomiting11/30/1986 5/1/2011 X X X LM 5/2/2011 NMK Allergies6/13/1971 5/1/2011 X X pt called X 5/2/2011 Dr Radosh Radosh CP5/14/2012 5/2/2011 X X X Radosh 5/16/2011 difficulty breathing, bronchitis9/30/1963 5/2/2011 X X X LM 5/3/2011 NMK Migraine12/2/1993 5/2/2011 X X X 5/3/2011 NMK 5/11/2011 Baxter Chest tightness2/18/1933 5/3/2011 X X X LM 5/4/2011 NMK Baxter Weakness, falls1/9/1983 5/3/2011 X X appt 5/18/2011 Martin anxiety, MH eval

8/23/1932 5/3/2011 X X X 5/4/2011 NMK 5/4/2011 Tilich SIRS Y11/12/1958 5/4/2011 X X X 5/5/2011 NMK 5/26/2011 Mancano Finger pain3/20/1964 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Peterson Itchy all over3/30/1961 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Peterson Change in mental status

12/24/1971 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Patel difficulty breathing10/19/1992 5/5/2011 X Obs X Martin Chest Pain

7/8/1967 5/5/2011 X X X 5/6/2011 NMK 5/9/2011 Abou Saab Allergic RXN Can't swallow12/31/1979 5/5/2011 X X X 5/6/2011 NMK not needed Raff Constipation, rectal pain

9/4/1955 5/6/2011 X X X 5/10/2011 NMK Abou Saab X4/24/1980 5/6/2011 X X X 5/10/2011 NMK Peterson Sore throat4/20/1947 5/7/2011 X X X 5/9/2011 5/9/2011 Hanafi Leg pain numbness5/6/1973 5/7/2011 X X X LM 5/10/2010 NMK Weida Side back pain Nausea

4/23/1938 5/7/2011 X X appt today 5/10/2010 NMK 5/10/2010 Mancano Fall7/11/1963 5/7/2011 X X pt called 5/10/2011 Baxter abdominal pain9/29/1968 5/7/2001 X X appt today 5/9/2011 NMK 5/9/2011 Cunningham Cough, congestion2/9/2007 5/7/2011 X X X 5/10/2011 NMK 5/20/2011 Peterson viral syndrome, chills

12/4/1933 5/8/2011 X X X 5/10/2011 NMK F/u cardiology Abn CV study Cardiology4/3/1996 5/8/2011 X X pt called 5/10/2011 NMK F/u hershey Warfel Migraine Hershey

11/1/2008 5/8/2011 X X X 5/10/2011 NMK not needed Weida eye complaint, cough10/19/1964 5/9/2011 X X appt NMK 5/17/2011 Raff X Diarrhea, Vomiting Y

2/9/1950 5/9/2011 X X pt scheduled 5/23/2011 Raff Poss HTN, HA12/30/1971 5/10/2011 X X had appt 5/23/2011 Raff CP, Abn Stress Test Cardiology

1/1/1983 5/10/2011 X X pt called 5/10/2011 5/18/2011 Radosh Pain in shoulder10/14/1975 5/10/2011 X X X 5/11/2011 NMK 5/12/2011 Shanmugam Shakey, multiple complaints1/22/2008 5/10/2011 X X X 5/11/2011 NMK 5/13/2011 Murphy Vomiting4/22/2011 5/10/2011 X X X LM 5/11/2011 NMK Lavrik Crying7/1/1964 5/11/2011 X X had appt 5/19/2011 Martin MVC7/8/1967 5/11/2011 X X X 5/12/2011 NMK 5/18/2011 Wang Anxiety Lt sided weakness

4/19/1969 5/11/2011 X X had appt 5/24/2011 Patel mouth pain2/16/1976 5/11/2011 X X had appt 5/13/2011 Peterson MVA9/10/1992 5/11/2011 X X had appt 6/2/2011 Lavrik abdominal pain6/23/1991 5/11/2011 X X X LM 5/12/2011 NMK Martin shoulder injury3/17/1972 5/12/2011 X X X LM 5/13/2011 NMK Peterson Chest Pain10/9/1938 5/18/2011 transfer to SNF X Nsg home Radosh SVT hypotensive episode7/2/1968 5/12/2011 X X X LM 5/13/2011 NMK Peterson injured toe

10/26/1979 5/12/2011 X X X NA 5/13/2011 NMK Patel abdominal pain9/17/1995 5/12/2011 X X X NA 5/13/2011 NMK Shanmugam Burning with urination4/10/1996 5/12/2011 X X X LM 5/13/2011 NMK Baxter Shoulder Pain1/5/1938 5/12/2011 X X X LM 5/13/2011 NMK Patel Open Choley

1/11/1973 5/13/2011 X X pt called 5/13/2011 5/16/2011 Tucker abdominal pain8/26/1953 5/13/2011 X X had appt 5/31/2011 Wang Finger Laceration

12/30/1991 5/13/2011 X X X LM 5/16/2011 NMK Abou Saab Ear Pain9/17/2009 5/13/2011 X X pt called 5/13/2011 5/18/2011 Martin accidental ingestion9/7/1963 5/14/2011 X X had appt 6/9/2011 Ekmark CP, SOB

12/1/1963 5/14/2011 X Obs X had appt 5/24/2011 Warfel CP, Asthma7/27/1974 5/14/2011 X X X 5/16/2011 NMK 5/25/2011 Lavrik Bronchitis

12/30/1966 5/14/2011 X X X 5/16/2011 NMK not needed Radosh Chest tightness5/5/1931 5/15/2011 X X X 5/16/2011 NMK 5/23/2011 Warfel Pneumonia

3/14/1966 5/15/2011 X X Baxter CP, High BP/cardiac cath cardiologist9/30/1988 5/15/2011 X X X 5/16/2011 NMK 5/23/2011 Malik head laceration3/24/1977 5/15/2011 X X X 5/16/2011 NMK 5/26/2011 Peterson HA, N & V4/22/1984 5/15/2001 X X had appt 5/17/2011 Arzomand Dizzy, side numbness1/2/2004 5/15/2011 X X had appt 6/2/2011 Peterson Dog bite

5/29/1970 5/16/2011 X X had appt 6/15/2011 Brigandi MVC4/24/1969 5/16/2011 X X X 5/17/2011 NMK not needed Weida Back pain, sinusitis/Bronchitis6/18/1950 5/16/2011 X X X 5/17/2011 NMK May-11 Wang Finger injury11/5/1986 5/16/2011 X X 5/17/2011 NMK not needed Ekmark Back pain11/8/1977 5/16/2011 X X had appt 5/20/2011 Tucker Coughing4/18/1940 5/18/2011 X X x Deloris yes 5/24/2011 Weida CA12/1/1963 5/19/2011 X X appt yes 5/24/2011 Warfel Asthma3/10/1950 5/19/2011 X X appt Deloris yes 5/25/2011 Doshi fever/ chst pain1/25/1962 5/21/2011 X X appt 6/2/2011 Radosh X2/4/1939 5/20/2011 X X appt yes 5/24/2011 Arzamand cellulitus cancelled appoint

12/26/1927 5/25/2011 X X appt Deloris yes 6/2/2011 Mancano presyncope5/20/1933 5/26/2011 transfer to SNF X Nsg Home Baxter CHF/ Pneumonia Deceased8/30/1952 5/26/2011 X X Warfel Pneumonia Threshold Client3/15/2029 5/27/2011 X X appt 6/15/2011 Lavrik Diarrhea/ Cervical Osteomylitis4/5/1977 5/27/2011 X X appt 5/31/2011 Raff Pancreatitis2/1/1947 5/28/2011 X X appt 6/1/2011 Campa Anemia

3/18/1960 5/27/2011 X X X LM 5/31/2011 NMK Patel Coughing blood4/24/1980 5/27/2011 X X X 5/31/2011 NMK 6/9/2011 Peterson Abdominal pain9/28/1951 5/27/2011 X X X LM 5/31/2011 NMK Baxter Toe injury4/23/1976 5/27/2011 X X X 5/31/2011 NMK Brigandi Knee Injury12/9/1964 5/28/2011 X X chart note 5/31/2011 6/8/2011 Weida Alcohol withdrawl Outpt detox

10/23/1978 5/28/2011 X X X 6/1/2011 NMK 6/6/2011 Lavrik Pelvic pain12/22/1976 5/29/2011 X X had appt 6/1/2011 Weida Rash7/19/1964 5/29/2011 X X X 6/1/2011 NMK not needed Lavrik HA, Nausea, Diarrhea5/17/1995 5/29/2011 X X X LM 6/1/2011 NMK Warfel dizziness & vomiting9/4/1932 5/30/2011 X X X LM 6/1/2011 NMK Brigandi Constipation9/5/2001 5/30/2011 X X X 6/1/2011 NMK 6/7/2011 Baxter nosebleed, dizzy

3/28/2008 5/30/2011 X X had appt 6/3/2011 Doshi side face swollen5/6/1951 5/31/2011 transfer to SNF chart note 5/31/2011 Malik Cunningham Osteomylitis RLE

7/10/1955 5/31/2011 X had appt 6/10/2011 Peterson spinal cord tumor8/23/1957 5/31/2011 X X X LM 6/1/2011 NMK Warfel Leg Pain4/24/1948 5/31/2011 X X X 6/1/2011 NMK 6/2/2011 Lavrik X

11/17/1942 5/31/2011 X X had appt 6/10/2011 Peterson Abdominal Pain2/10/1987 5/31/2011 X X had appt 6/3/2011 Warfel Lump on neck6/22/1998 5/31/2011 X X X 6/1/2011 Martin 6/3/2011 Murphy X Pneumonia7/24/1963 5/31/2011 X X had appt 6/2/2011 Peterson Leg pain & swelling11/3/2025 5/31/2011 X X X 6/1/2011 NMK 6/13/2011 Baxter Difficulty speaking

FHCC follow-up? CM/PCP Notification? MAIN reason for ER visit/hospitilzationDemographic Information Setting Facility Contacted?

Name DOB MR#Date of

D/C ER?Hosp

discharge? TRHMC?Other

(which?)Phone call

made?Date of contact Contacted by

FHCC F/U App't Made?

Date of FHCC f/u

11/30/1932 5/1/2011 X X had appt 5/9/20116/19/1990 5/1/2011 X X X LM 5/2/2011 NMK4/11/1978 5/1/2011 X X X 5/2/2011 NMK8/17/1984 5/1/2011 X X X 5/2/2011 NMK not needed

10/19/1964 5/1/2011 X X appt tomorrow 5/2/2011 NMK 5/3/201111/30/1986 5/1/2011 X X X LM 5/2/2011 NMK6/13/1971 5/1/2011 X X pt called X 5/2/2011 Dr Radosh5/14/2012 5/2/2011 X X X Radosh 5/16/20119/30/1963 5/2/2011 X X X LM 5/3/2011 NMK12/2/1993 5/2/2011 X X X 5/3/2011 NMK 5/11/20112/18/1933 5/3/2011 X X X LM 5/4/2011 NMK1/9/1983 5/3/2011 X X appt 5/18/2011

8/23/1932 5/3/2011 X X X 5/4/2011 NMK 5/4/201111/12/1958 5/4/2011 X X X 5/5/2011 NMK 5/26/20113/20/1964 5/4/2011 X X X 5/5/2011 NMK 5/6/20113/30/1961 5/4/2011 X X X 5/5/2011 NMK 5/6/2011

12/24/1971 5/4/2011 X X X 5/5/2011 NMK 5/6/2011

FHCC follow-up?Demographic Information Setting Facility Contacted?

In CM Registry prior to

d/c?Responsible

Provider

Resp prov

notified? Asthma CHF COPDBronchitis/URI/

PneumoniaOrtho/MS

Pain HA

Hyperglycemia/La

b issueDepression/

anxietyOther (list main

dx)

Was pt on FHCC service (adm only)?

Non-FHCC referrals

Action plan

Safety issues Comments

Cunningham XPatel Pain all over YPeterson vomitingShanmugam boil/mole changeRaff Diarrhea, Vomiting

AllergiesRadosh CP

difficulty breathing, bronchitisMigraine

Baxter Chest tightnessBaxter Weakness, fallsMartin anxiety, MH evalTilich SIRS YMancano Finger painPeterson Itchy all overPeterson Change in mental statusPatel difficulty breathing

CM/PCP Notification? MAIN reason for ER visit/hospitilzation

Sample: EMR Chart Note (Done by Physician)

Discharge Instructions: PDF Faxed at Moment of D/C

RRC “Plug” ACGME competencies require this kind of

work Transitional care counts!

Residents can: Design plans/assist with development of

policies Do med rec, home visits

Residents + transitional care =“system-based practice” competency

$$$ Improved office efficiency?

More volume for 99214’s? Piece of the pie?

Get money or assistance (care managers, etc.) via hospital bundled payments

Pay for performance? TOC metrics part of clinical integration bonuses

New CPT codes?

99495 and 99496

• Cover transitional care management (TCM) services as the patient is transitioning from inpatient hospital care to his or her home or another community setting Moderate decision-making: 99495 High-complexity medical decision-making: 99496

Approved by CMS last fall; became available to physician practices in January 2013

Tools for New Codes http://www.aafp.org/dam/AAFP/documents/practi

ce_management/payment/TCMFAQ.pdf Great two-page PDF summary by AAFP

http://www.aafp.org/dam/AAFP/documents/practice_management/payment/TCM30day.pdf Great two-page PDF worksheet by AAFP

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf Eight-page PDF by CMS delineating details

Worth It? Are the new codes worth the time and

effort? We’ll see . . .

“This is way too complicated. I cannot track these charges and make sure they get billed out 30 days after discharge. We send claims same day or next day. Holding work for later is just asking for missed charges. Also I don't get DC info until 4-5 days after discharge, if ever. I have one staff member so saying staff can do this is ridiculous since she is already doing a lot and she is not a clinical person. What if send the charge out and find out later they were readmitted on day 28? This is not practical or feasible. I will not use this code. The increased pay is not worth the hassle.”

From FPM Blog

“. . .. I agree. It seems easier to continue to bill the usual E and M code rather than remember to bill the 30 th day. Seeing the patient is important after discharge so I wouldn't want to discourage that visit. Unless the coordination code pays a lot more than the usual 99214 it seems worthless. We will continue to do uncompensated work.”

“How much are these new services worth?” (from AAFP link)

“Payment allowances will vary by payer, and Medicare’s allowance will vary geographically. Also, Medicare’s allowance will depend on the conversion factor in force at the time claims are paid.

Based on these RVUs and the current (2012) conversion factor, the Medicare allowance for code 99495 performed in a non-facility setting (e.g., a physician’s office) would be approximately $164; in a facility setting, the corresponding allowance would be approximately $135. For code 99496 performed in a non-facility setting, the Medicare payment allowance would be approximately $231.12; when performed in a facility setting, it would be approximately $197.76.”

Finally . . .

Be an advocate! This is where Family Medicine should shine

And get paid more . . .

Get involved Clinically integrated entities – committees Health system task forces Medical societies

Objectives (Met?)

By the end of this presentation, participants will be able to: List external forces related to transitional care Identify “priority tasks” in transitional care

Have appointment made prior to discharge Medication reconciliation (by phone or in person) Discharged patient should be seen within __ days Develop a registry of some sort (high-risk patients)

Utilize tools to augment your planning Identify new CPT codes

To Do Tomorrow: Inventory: what hospital(s) do your patients go to?

Complete the transitional tool Call the contact – how can you get daily ED/discharge lists?

Have a meeting at your practice How can hospital patients get app’t prior to d/c?

Meet with inpatient care managers?

Take inventory: what medication reconciliation processes do you have, if any?

Who can/should do it, when, how (phone?) Are you seeing dc’d patients for hospital f/u soon? Do you have some type of registry for high-risk patients

(frequent flyers)? Do patients get contacted? When/how often/by whom?

Take Home Messages

Transitional care is gaining press, importance, and soon - reimbursement

Choose key areas Discharges, med rec, f/u visit, high-risk registry Prevent re-admissions!

Start with specific tasks Small, concrete steps

Do NOT re-invent the wheel There is a lot of material out there

Be an advocate for this – don’t do it for free!

THANK YOU FOR YOUR ATTENTION!

Questions/comments?

Experiences/ideas to share?