Transcript Document
Transitional care management (TCM): A team approach to facilitating transitions of care in a Gerontology Clinic
Carol O’Leary, Jeffrey Kochka, Virginia Dolan, Suzanne Salamon, MD, Scot B. Sternberg, MS
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
A teaching hospital of Harvard Medical School
Problem:
Transitions of care from a hospital or rehabilitation stay to home present many challenges for patients, particularly for the elderly, and their outpatient care provider. Patients discharged are at higher risk for discontinuity in care, decompensation, and readmission to the hospital without coordination among care providers and patient. In 2013, Medicare offered beneficiaries a new covered service, Transitional Care Management (TCM). Licensed providers could be reimbursed for providing TCM services including non-face-to-face outreach to the patient within 2 days of discharge to review their discharge care plan and coordinate services, and a visit within 7-days or 14-days of discharge (depending on medical complexity) to evaluate, provide and manage care.
Aim/Goal:
Implement team-based TCM services for patients in the Gerontology Clinic.
Improve coordination in transitions of care
Description of the Intervention, including context
In collaboration with the Department of Medicine, BIDMC and HMFP compliance and billing, Gerontology developed a plan for the clinic and staff to pilot and roll out TCM services.
Administrative clinic staff, in coordination with providers, designed the process, patient call scripts, and a database for tracking.
In FY2013 Q4, July – September, the Gerontology Clinic piloted TCM services patients discharged from the hospital.
For FY2014, beginning October 2013, TCM services were offered for all patients discharged from the hospital identified by daily discharge reports.
TCM services were further enhanced with the addition of a nurse in the clinic who reviews care plans and medications in more detail with patients.
In June 2014, the Gerontology Clinic expanded TCM services to patients discharged from rehabilitation.
Transitional Care Management (TCM) Identified and Completed By Quarter in Gerontology
60 50 40 30 20 Expanded TCM for Patients discharged from Rehab 10 Initiated pilot of TCM for Patients discharged from hospital 0 July-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 TCM Identified and Scheduled Apr-June 2014 July-Sept 2014 TCM Completed and Billed Oct-Dec 2014 When patients were identified at time of discharge, a team-based TCM was successfully implemented for 70-80% of patients in Gerontology TCM was not completed when patients were cancelled post discharge visit or unable to schedule within 7 to 14-day window required by Medicare TCM was expanded to include patients discharged from rehabilitation Patients and families expressed appreciation for the TCM outreach calls and prompt access to visit with their primary care clinician Data on readmission rates for patients who received TCM services was not available at the time of this report
Key Lessons Learned
Non-physician staff (administrative and nurses) can facilitate transitions of care completion of referrals, thus reducing overall administrative burdens on primary care physicians and employing a top of license strategy. Many patients value the outreach and availability of their care team following discharge, though some patients were unable to attend a visit within timeframe
Next Steps
Continue TCM services.
Assess impact on readmission rates and patient experience.
Implement Chronic Care Management and broader care management strategies within care team .
¹ This initiative has been funded, in part, by a grant from the CRICO patient safety program.
² CRICO (2012) Referral Management Guidelines, developed with contributions by the Referral Management Workgroup (RMW) members