Transition of Care Tip Sheet Definition Managing and

  • Slides: 1
Download presentation
Transition of Care Tip Sheet Definition: Managing and coordinating a patient’s care as they

Transition of Care Tip Sheet Definition: Managing and coordinating a patient’s care as they move from one care setting to another as their health status changes Care Team Registered Nurse (preferred) with potential delegation of ER/UC tasks Objective s Reduce Readmissions Decrease ER/Hospital Utilization Improve Patient Outcomes Reduce Total Cost of Care Improve Patient Satisfaction Tools • ADT access Inbound hospital, ER, UC documentation Transition of Care Template Process • Medical/ Behavioral Health. • Inpatient/ER/UC/ • Behavioral Medication Health reconciliation • Contact within days for completed on 2 or before inpatient the date of the face-toface visit. • Contact within 7 days of • discharge Documentation of for ER/UC discharge summary • Med Rec completed in medical record. • • Ensure documentation Schedule follow up ofindischarge office. summary in medical • Schedulerecord follow up for outpatient laboratory, • Schedule follow up in diagnostics, office specialists. • Schedule follow up for outpatient laboratory, • diagnostics, Referrals to specialists community • Referral to community resources, as resources, needed. as needed • Referral to Care Management/Behavioral Health Care Management, when required. • Contact within 7 days of discharge from ER/UC. Billing • Telephonic contact with patient and/or caregiver within 2 business days of discharge • Face-to-Face visit within 14 days of discharge • Medical decision making of at least moderate complexity during service CPT Code 99495 period • Telephonic contact with patient and/or caregiver within 2 business days of discharge • Face-to-Face visit within 7 days of discharge • Medical decision making of at least high complexity during service period CPT Code 99496 CPT II Code 1111 F • Supplemental tracking code for some insurances • Completion of Medication reconciliation • Telephonic contact with patient and/or caregiver within 2 business days of discharge Observed Benefits $2, 632 % % Observed Annual TOC Codes Billed per 1000 patients 56 % 24% $2, 750, 000 Observed Annual TOC Revenue per 1000 patients % Observed Reduction in ER/Hospital Utilization Reduction in Medical Expense