PAL South Cocoa Family Medicine Cornerstone Family Health Assoc. Eastbrook Family Health Center Elizabethtown Family Health Center White Rose Family Practice Transition of Care (TOC) Workflow
Kissel Hill Family Care Manor Family Health Center Mountville Family Practice Assoc. Oyster Point Family Health Center Red Rose Pediatrics Assoc.
Subject
Date Issued
Date Revised
Date Effective
Transition of Care
01/01/2013
02/17/17
02/17/17
Purpose: To provide a process for contacting patient for follow up care post discharge. Guidelines: Quality team/clinical team will identify patients recently discharge from the hospital. Patients will be contacted, assessed on their understanding of current medications, how they are feeling presently, and to ensure a follow up appointment is scheduled with the primary care physician within 714 days post discharge. Procedure: Patient contact within 2 business days post discharge. 1.
Site discover the patient has been discharged. a. Keep a list of patients that are in the hospital, should be printed daily. Also use PAR80. b. Check to see if any patients have been discharged, they will drop off the list. c. Print hospital discharge, medication list, any recent labs, (CMP, CBC, etc.). When printing labs, print admission labs and most recent two and include any labs that are not routinely order, (folate, retic, iron studies, etc.). d. Print any diagnostic imaging and cardiology. e. Abstract any labs that need to be abstracted.
2.
Create a TOC Nurse Note. a. Two attempts need to be made in order to bill for TOC-, document in note. b. Continue attempts until patient is reached – document.
PAL South Cocoa Family Medicine Cornerstone Family Health Assoc. Eastbrook Family Health Center Elizabethtown Family Health Center White Rose Family Practice
Kissel Hill Family Care Manor Family Health Center Mountville Family Practice Assoc. Oyster Point Family Health Center Red Rose Pediatrics Assoc.
TOC workflow continued
c. Complete any information that can be completed prior to calling the patient, hospital dates, reason for hospitalization, and update medication list. Medications will be verified when patient is contacted. d. Nurse will discuss with patient an array of touch points including but not limited to their understanding of medication, barriers to continued care, support system, etc. If questions arise that the nurse is unable to address or has concerns regarding patient, the nurse will task the provider for advice or to follow up with patient. e. Calculate LACE score. i. If score is >= to 10, refer to case management, buy using an order. ii. Let patient know a case manager from their insurance may be contacting them to review programs that are offered that may assist the patient. 2. Schedule a TOC appointment with in 7-14 days post discharge, with discharge date counting as day one. 3. See patient using a TOC note.
4.
The medication reconciliation button MUST be clicked by provider at visit as per STARS measure. If that button is clicked, the TOC code will explode to include CPT code 1111F when charged out.
PAL South Cocoa Family Medicine Cornerstone Family Health Assoc. Eastbrook Family Health Center Elizabethtown Family Health Center White Rose Family Practice
Kissel Hill Family Care Manor Family Health Center Mountville Family Practice Assoc. Oyster Point Family Health Center Red Rose Pediatrics Assoc.
5. Bill the 99495/99496. 6. The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The date of service you report should be the date of the required face-to-face visit. You may submit the claim once the face-to-face visit is furnished and need not hold the claim until the end of the service period. It is best practice to hold billing until the 30 th day, while using the DOS as the face to face date. 7. If patient is admitted and discharged within the 30 days, the second discharge will now become the TOC. Bill the first TOC as an E&M code.
Patient contact NOT within 2 business days. 1.
Site discovers patient has been discharged.
TOC workflow continued 2. Nurse starts TOC nurse note and copies the information provided by the notification they received. 3. The nurse does not call the patient if site was notified by Case Management, as all the pertinent information would have been collected. 4. Nurse will ensure a follow up appointment is scheduled within 7-14 days.
PAL South Cocoa Family Medicine Cornerstone Family Health Assoc. Eastbrook Family Health Center Elizabethtown Family Health Center White Rose Family Practice
Kissel Hill Family Care Manor Family Health Center Mountville Family Practice Assoc. Oyster Point Family Health Center Red Rose Pediatrics Assoc.
