Designing Winning "Transitions of Care" Processes!

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 Winning
Transitions 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

Designing Winning "Transitions of Care" Processes!

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

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

PatientName(Last,First):_______________________________________ DOB:_______________
Date/TimeofCall(s)attemptedbutnotcompletedwithcallerinitials:
1)______________________________ 2)______________________________ 3)_______________________________
Messagescript:“Hellothisis_________. I‟mcallingfrom_________asafollowupfromyourhospitalization.Someonefrom
ourofficewilltrytoreachyouagaintomorrow,butpleasefeelfreetocallbacktodayat(officenumber)andaskfor_________.”
Ifunabletoreachpatientafterthreeattempts,datecertifiedlettersentwithmailerinitials:________________________
Date/Timecallcompletedwithcallerinitials:______________________________
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___.”
(SeeDischargeInstructionsheet,sectionReasonfor
Admission/DiagnosisandProblems)
“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 ________ ? “ (listADDITIONAL
TESTSondischargeinstructionsheet)
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/HowtoGuideImprovingTransitionstoR
educeAvoidableRehospitalizations.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 COPD
Bronchitis/URI/
Pneumonia
Ortho/MS
Pain HA
Hypergly
cemia/La
b issue
Depression/
anxiety
Other (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 X
6/19/1990 5/1/2011 X X X LM 5/2/2011 NMK Patel Pain all over Y
4/11/1978 5/1/2011 X X X 5/2/2011 NMK Peterson vomiting
8/17/1984 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, Vomiting
11/30/1986 5/1/2011 X X X LM 5/2/2011 NMK Allergies
6/13/1971 5/1/2011 X X pt called X 5/2/2011 Dr Radosh Radosh CP
5/14/2012 5/2/2011 X X X Radosh 5/16/2011 difficulty breathing, bronchitis
9/30/1963 5/2/2011 X X X LM 5/3/2011 NMK Migraine
12/2/1993 5/2/2011 X X X 5/3/2011 NMK 5/11/2011 Baxter Chest tightness
2/18/1933 5/3/2011 X X X LM 5/4/2011 NMK Baxter Weakness, falls
1/9/1983 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 Y
11/12/1958 5/4/2011 X X X 5/5/2011 NMK 5/26/2011 Mancano Finger pain
3/20/1964 5/4/2011 X X X 5/5/2011 NMK 5/6/2011 Peterson Itchy all over
3/30/1961 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 breathing
10/19/1992 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 swallow
12/31/1979 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 X
4/24/1980 5/6/2011 X X X 5/10/2011 NMK Peterson Sore throat
4/20/1947 5/7/2011 X X X 5/9/2011 5/9/2011 Hanafi Leg pain numbness
5/6/1973 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 Fall
7/11/1963 5/7/2011 X X pt called 5/10/2011 Baxter abdominal pain
9/29/1968 5/7/2001 X X appt today 5/9/2011 NMK 5/9/2011 Cunningham Cough, congestion
2/9/2007 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 Cardiology
4/3/1996 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, cough
10/19/1964 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, HA
12/30/1971 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 shoulder
10/14/1975 5/10/2011 X X X 5/11/2011 NMK 5/12/2011 Shanmugam Shakey, multiple complaints
1/22/2008 5/10/2011 X X X 5/11/2011 NMK 5/13/2011 Murphy Vomiting
4/22/2011 5/10/2011 X X X LM 5/11/2011 NMK Lavrik Crying
7/1/1964 5/11/2011 X X had appt 5/19/2011 Martin MVC
7/8/1967 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 pain
2/16/1976 5/11/2011 X X had appt 5/13/2011 Peterson MVA
9/10/1992 5/11/2011 X X had appt 6/2/2011 Lavrik abdominal pain
6/23/1991 5/11/2011 X X X LM 5/12/2011 NMK Martin shoulder injury
3/17/1972 5/12/2011 X X X LM 5/13/2011 NMK Peterson Chest Pain
10/9/1938 5/18/2011 transfer to SNF X Nsg home Radosh SVT hypotensive episode
7/2/1968 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 pain
9/17/1995 5/12/2011 X X X NA 5/13/2011 NMK Shanmugam Burning with urination
4/10/1996 5/12/2011 X X X LM 5/13/2011 NMK Baxter Shoulder Pain
1/5/1938 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 pain
8/26/1953 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 Pain
9/17/2009 5/13/2011 X X pt called 5/13/2011 5/18/2011 Martin accidental ingestion
9/7/1963 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, Asthma
7/27/1974 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 tightness
5/5/1931 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 cardiologist
9/30/1988 5/15/2011 X X X 5/16/2011 NMK 5/23/2011 Malik head laceration
3/24/1977 5/15/2011 X X X 5/16/2011 NMK 5/26/2011 Peterson HA, N & V
4/22/1984 5/15/2001 X X had appt 5/17/2011 Arzomand Dizzy, side numbness
1/2/2004 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 MVC
4/24/1969 5/16/2011 X X X 5/17/2011 NMK not needed Weida Back pain, sinusitis/Bronchitis
6/18/1950 5/16/2011 X X X 5/17/2011 NMK May-11 Wang Finger injury
11/5/1986 5/16/2011 X X 5/17/2011 NMK not needed Ekmark Back pain
11/8/1977 5/16/2011 X X had appt 5/20/2011 Tucker Coughing
4/18/1940 5/18/2011 X X x Deloris yes 5/24/2011 Weida CA
12/1/1963 5/19/2011 X X appt yes 5/24/2011 Warfel Asthma
3/10/1950 5/19/2011 X X appt Deloris yes 5/25/2011 Doshi fever/ chst pain
1/25/1962 5/21/2011 X X appt 6/2/2011 Radosh X
2/4/1939 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 presyncope
5/20/1933 5/26/2011 transfer to SNF X Nsg Home Baxter CHF/ Pneumonia Deceased
8/30/1952 5/26/2011 X X Warfel Pneumonia Threshold Client
3/15/2029 5/27/2011 X X appt 6/15/2011 Lavrik Diarrhea/ Cervical Osteomylitis
4/5/1977 5/27/2011 X X appt 5/31/2011 Raff Pancreatitis
2/1/1947 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 blood
4/24/1980 5/27/2011 X X X 5/31/2011 NMK 6/9/2011 Peterson Abdominal pain
9/28/1951 5/27/2011 X X X LM 5/31/2011 NMK Baxter Toe injury
4/23/1976 5/27/2011 X X X 5/31/2011 NMK Brigandi Knee Injury
12/9/1964 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 pain
12/22/1976 5/29/2011 X X had appt 6/1/2011 Weida Rash
7/19/1964 5/29/2011 X X X 6/1/2011 NMK not needed Lavrik HA, Nausea, Diarrhea
5/17/1995 5/29/2011 X X X LM 6/1/2011 NMK Warfel dizziness & vomiting
9/4/1932 5/30/2011 X X X LM 6/1/2011 NMK Brigandi Constipation
9/5/2001 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 swollen
5/6/1951 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 tumor
8/23/1957 5/31/2011 X X X LM 6/1/2011 NMK Warfel Leg Pain
4/24/1948 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 Pain
2/10/1987 5/31/2011 X X had appt 6/3/2011 Warfel Lump on neck
6/22/1998 5/31/2011 X X X 6/1/2011 Martin 6/3/2011 Murphy X Pneumonia
7/24/1963 5/31/2011 X X had appt 6/2/2011 Peterson Leg pain & swelling
11/3/2025 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 5/9/2011
6/19/1990 5/1/2011 X X X LM 5/2/2011 NMK
4/11/1978 5/1/2011 X X X 5/2/2011 NMK
8/17/1984 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 5/3/2011
11/30/1986 5/1/2011 X X X LM 5/2/2011 NMK
6/13/1971 5/1/2011 X X pt called X 5/2/2011 Dr Radosh
5/14/2012 5/2/2011 X X X Radosh 5/16/2011
9/30/1963 5/2/2011 X X X LM 5/3/2011 NMK
12/2/1993 5/2/2011 X X X 5/3/2011 NMK 5/11/2011
2/18/1933 5/3/2011 X X X LM 5/4/2011 NMK
1/9/1983 5/3/2011 X X appt 5/18/2011
8/23/1932 5/3/2011 X X X 5/4/2011 NMK 5/4/2011
11/12/1958 5/4/2011 X X X 5/5/2011 NMK 5/26/2011
3/20/1964 5/4/2011 X X X 5/5/2011 NMK 5/6/2011
3/30/1961 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 COPD
Bronchitis/URI/
Pneumonia
Ortho/MS
Pain HA
Hypergly
cemia/La
b issue
Depression/
anxiety
Other (list main
dx)
Waspt on
FHCC service
(adm only)?
Non-FHCC
referrals
Action
plan
Safety
issues Comments
Cunningham X
Patel Pain all over Y
Peterson vomiting
Shanmugam boil/mole change
Raff Diarrhea, Vomiting
Allergies
Radosh CP
difficulty breathing, bronchitis
Migraine
Baxter Chest tightness
Baxter Weakness, falls
Martin anxiety, MH eval
Tilich SIRS Y
Mancano Finger pain
Peterson Itchy all over
Peterson Change in mental status
Patel 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/practice_
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?

Designing Winning "Transitions of Care" Processes!

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Designing Winning "Transitions of Care" Processes!