Transitions of care - practice management strategies and tools

1. Transitions of care - practice management strategies and tools Chandana Tripathy m.D.Neela K. patel m.d. DeAnora l Cadengo-Esparza, Lead LVN Juanita Martinez ma

2. Objectives • 1To enlist processes to design an optimal Transition of Care workflow in your practice • 2 To discuss successful interventions to reduce admissions for Ambulatory Care Sensitive Conditions (ACSC)

3. The Centers for Medicare & Medicaid Services (CMS) definesa transition of care - As the movement of a patient from one setting of care to another. - Settings of care include Hospitals Ambulatory primary care practices and ambulatory specialty care practices SNF/long-term care facilities Home health Post acute Care/ rehabilitation facilities

4. Why is this Important ? • Transitions increase the risk of adverse events due to the potential for miscommunication as responsibility is given to new parties. • Hospital discharge is a complex process representing a time of significant vulnerability for patients. • Safe and effective transfer of responsibility for a patient’s medical care relies on effective provider communication with patient comprehension of discharge instructions

5. Why was it our focus ? Our clinics did not have a standardized flow to follow up patients during transitions and clinic was missing TOC attendance

6. UT Senior Health clinic - NP led Model A sustained quality improvement initiative to increase attendance to transition of care clinic following hospital discharge thereby ensuring safe transitions and reduced readmissions

8. BILLING TCM SERVICES

10. Our Focus

11. Improve patient awareness • Visible information regarding TOC services made available in the patient waiting area • Mass email to all patients about the TOC clinic • Visible signs in patient rooms • Colorful handout for all UT senior health patients who are being discharged from the Inpatient/ACE unit • Colorful Handouts for all patients who come to the clinic

12. Improve staff awareness • Team of staff consistently available to address TOC visits • Establish a process from hospital /ACE unit to home or rehab facility • During the week days, the ACE Unit Nurse practitioner will send EHR messages about patient discharge • ACE trainees/residents trained to send EHR messages to PCP about patient discharge

13. TOC CLINIC • The TOC clinic was led by a nurse practitioner (NP) who runs the interdisciplinary team, rounds in the hospital and also sees patients in the ambulatory clinic. • The NP is familiar with the patients and has access to all records.

14. TOC CLINIC - NP led Model • The TOC clinic has a 3 step process. • A hospital team sends an electronic message to the ambulatory team about patient discharge with a detailed discharge summary. • Clinic team calls the patient and verifies medications, referrals and makes TOC appointment. • Patient and family are educated about the TOC clinic and advised to call the clinic within 24 hours of discharge.

15. Outcomes • Attendance to TOC clinic increased from 20% in 2014 to 90% in 2016. • Readmissions have reduced to 3.2% compared to 12% for the other hospitalist groups for all admissions

16. Outcome Patients transitioning from rehabilitation are followed as well. TOC clinic led to coordinated care across different settings. • It also improved patient satisfaction for both hospital and ambulatory clinic. • There is return on investment –patient outcomes, fee for service reimbursements higher, savings to hospital – shared savings program.

17. Conclusion • This program has sustained since November 2014 and has grown to all hospital and rehabilitation discharges. • This is a unique nurse practitioner led transition of care program that can be replicated/implemented by other organizations and programs as well.

18. Case Manager led model at UT Health MARC Primary Care • MARC primary is a large practice with FM/IM and geriatric providers • Patients from various geographic location in town come to our practice hence patients got admitted to almost any hospital system across San Antonio • Our providers did not see them in hospital • Our challenges -Lack of timely notification about discharges -Lack of available discharge summary during TOC visit -No standardization of workflow for discharged patients - Inconsistent TOC attendance A dedicated RN Case Manager to coordinate transition of care

19. Process changes at the MARC practice • Staff Education and Training • Call Center and Front desk staff were trained about CMS guidelines for transition visits and why timely processing of these notifications to clinic must happen • Intake team and LVN – handling fax and telephone notification were educated about timely processing and 48 hrs ( within 2 business days) outreach/ interactive contact requirement • Patient Education • During intake /during office visit and after visit summary blurb • Patients educated to contact clinic first for new medical issues • Patients educated to notify clinic if for some reason they did go straight to ER/urgent care or hospital.

20. Case Manager Role 1 Access for various hospital EHR portals so discharge summary was available for transition visits 2 Provide access to HASA lists –secure electronic exchange of patient data 3 All TOC patients received an outreach call within 48 hours of discharge to complete -medication reconciliation • -patient education and in preparation for TOC visit with MD • labs /DME/Home health order was facilitated by case manager 4 TOC visit preparation – Case Manager met with patient before MD and updated MD of any deviations missing medications etc 5 Post TOC visit outreach

21. Process changes at the MARC practice Schedule optimization to make room for TOC visits PCP schedule has a dedicated MD only slot that stays locked upto 14 days for use for TOC visit Float MD condusts weekly TOC clinic - overflow for PCP when out of office or when PCP was fully booked

22. Improvement initiative to reduce admissions for ambulatory Care sensitive conditions ( ACSC) ACSC are medical conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.

23. Episode records review 45 Medicare patients charts were reviewed Site : MARC Primary Care Admission Year 2015

24. Ambulatory Care Sensitive Conditions Admission Diagnosis : Acute conditions • Pneumonia 7 • Acute renal Failure 6 • UTI 5 • Dehydration 3 • Septicemia 1 Chronic Conditions • CHF acute on chronic HFpEF/HFrEF 8 • Acute Bronchitis /Asthma /COPD 6 • Uncontrolled DM2 5

25. Metrics used for chart review • No show prior to admission – No show or failure to schedule a FU /left office without a disposition • Failed to contact clinic with clinical symptoms prior to admission • Failure of clinic to return phone call or respond to a patient message on our secure patient portal • Did the clinic return call timely • Failure of clinic to act on abnormal lab or tests leading to admission • No FU in clinic in last 1 year • Failure to notify clinic about admission • Advanced Directives scanned in EHR

26. Metrics used for chart review –contd Failure to notify clinic about hospital admission Discharge records not available during TOC visit Post TOC visit was the next FU at a optimal time interval Readmission 7-30 days Patient failed to follow treatment plan

27. Results of episode review • No admission was as a result of a oversight of abnormal labs • All admitted patients had been seen in clinic in last 1 year

28. Results of episode review – problem areas 12% patients in episode review had no showed to clinic visit or left clinic without setting up an appointment 50 % patients did not have an optimal follow up following a TOC visit 21 % of patients did not follow proposed treatment plan

29. Work flow changes based on episode review results 1 Focus on No shows Daily MA provider huddles to indentify high risk no-shows TOC No shows - contacted by case Manager 2 Focus on ensuring patient scheduled a follow up appointment Check out station were created Front desk reviewed completed visits to ensure every patient that was seen has follow up appointment scheduled

30. Work flow changes based on episode review results 3 Close FU following TOC visit PCP will formulate a close follow up plan in collaboration with patient 1-2 week visit with advanced practitioner NP/PA or Case manager outreach – phone call or Home health update

31. Work flow changes based on episode review results • Identify barriers to follow instructions • Enroll in appropriate health team: • Pharm D • Case Manager coaching • Behavioral Health

32. Weekly admission and discharge huddles • Case Manager presented weekly tally of admissions and TOC visits • Analysis of TOC cases for missed opportunity • Revamp Patient education regarding need to contact clinic when in ER or hospital • Continued staff training especially when onboarding new staff and faculty regarding significance of safe transitions and following standard TOC work flow

33. Future steps • Invest in EHR interface to get real time notification about ER and hospital admission for our patients • After hour clinics • Better Collaboration with hospital /post acute care and longterm care facilities • Optimizing our team members around high utilizers • Telemedicine use

34. Transition of care (TOC) Billing Codes • 2 CPT codes for payment during Transition of care service period: • 99495 7 day post discharge • 99496 14 day post discharge

35. Transition of care billing rules • Report services once per beneficiary during the TOC period. • The same health care professional may discharge the beneficiary from the hospital, report hospital or observation discharge services, and bill TOC services. • However, the required face-to-face visit may not take place on the same day you report discharge day management services. • Report reasonable and necessary evaluation and management (E/M) services (other than the required face-to-face visit) to manage the beneficiary’s clinical issues separately.

36. Transition of care billing rules • You may not bill TOC services and services that are within a post-operative global period (TOC services cannot be paid if any of the 30-day TOC period falls within a global period for a procedure code billed by the same practitioner). • When you report CPT codes 99495 and 99496 for Medicare payment, you may not also report these codes during the TOC service period: • • Care Plan Oversight Services • • Home health or hospice supervision: HCPCS codes G0181 and G0182 • • End-Stage Renal Disease services: CPT codes 90951–90970

37. Interactive contact • An interactive contact must be made with the beneficiary and/or caregiver, within 2 business days following the beneficiary’s discharge to the community setting. • The contact may be via telephone, email, or face-to-face. • It can be made by you or clinical staff who have the capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care • For Medicare purposes, attempts to communicate should continue after the first two attempts in the required 2 business days until they are successful. If you make two or more separate attempts in a timely manner and document them in the medical record but are unsuccessful, and if all other TOC criteria are met, you may report the service. • We emphasize, however, that we expect attempts to communicate to continue until they are successful. You cannot bill TOC if the face-to-face visit is not furnished within the required timeframe .

38. Non Face to Face Service You must furnish non-face-to-face services to the beneficiary, unless you determine that they are not medically indicated or needed. Clinical staff under your direction may provide certain non-face-to-face services. Services Furnished by Physicians or NPPs Physicians or NPPs may furnish these non-face-to-face services Obtain and review discharge information (for example, discharge summary or continuity of care documents) ™

39. Non face to face service –contd Review need for or follow-up on pending diagnostic tests and treatments ™ -Interact with other health care professionals who will assume or reassume care of the beneficiary’s system-specific problems ™ -Provide education to the beneficiary, family, guardian, and/or caregiver ™ -Establish or re-establish referrals and arrange for needed community resources ™ -Assist in scheduling required follow-up with community providers and services

40. Questions ?