Overview of the hospital discharge process as it relates to the development of a new transition of care clinic aimed at reducing the rate of hospital readmissions.
4. On Hospital Admission – Part 1
Estimate LOS
Progress to Discharge
Anticipated
Disposition
New SNF
Placement
PT/OT
Evaluation
Arrange SNF
Placement
Home or
Continued SNF
5. On Hospital Admission – Part 2
Progress to Discharge
PT/OT
Order PT/OT
Evaluation
Arrange for
identified
needs
Quality
Measures
Assess for QM
Compliance
Address QM
Needs
DME/O2
Order DME/O2
Evaluations
Arrange for
identified
needs
Financial
SW/PCF
Evaluation
Arrange for
identified
needs
6. On Hospital Admission - 3
Progress to Discharge
Financial
SW/PCF
Evaluation
Arrange for
identified
needs
Education
Assess for
Educational
Needs
Address
Educational
Needs
PCP
Determine if pt
needs PCP
Refer to
potential PCPs
Transportation
Determine if pt
needs
transport
Arrange
Transport
8. Pre Discharge Day – Part 1
Discharge
Is Inpatient
Therapy
Complete?
Disposition
Needs
Needs Met
and Arranged
Consultants
Follow Up
Needed?
Arrange for
Follow Up
Communicate
with PCP
PCP Notified
Flags/Phone
Arrange for
Follow Up
Yes
Continue
Inpatient
Therapy
No
Process to Discharge
9. Pre Discharge Day – Part 2
Discharge
Medication
Reconciliation
MedRec Draft
Forms
Complete
Forms
DC Summary
Dictate Draft
Face to Face
Out of Hospital DNR
FMLA
DME Orders
Circle and sign
EHR MedRec
Quality
Measures
Recheck
Assess for QM
Compliance
Address QM
Needs
11. Discharge Day – Part 1
Discharge
Medication
Reconciliation
MedRec
Complete
Update PCPForms
Complete
Forms
Face to Face
Out of Hospital DNR
FMLA
DME Orders
Circle and sign
EHR MedRec
Final Review
Update
Consultants
Update DC
Plans
Discharge
Orders
Complete by
10AM
12. Discharge Day – Part 2
Discharge
Need Labs for
TOCC?
Order Labs
Discharge PtDC Summary
Complete DC
Summary
Appropriate
for TOCC?
Schedule for
TOCC
14. Phone Call
Transitioning to PCP
Clinical Status
Medication
Reconciliation
Encourage
taking
Medications
Education
Provide
needed
education
Follow Up
Confirm
Appointments
Phone call by hospitalist nurse, MD, or NPP
15. Phone Call – Documentation Required
• Discharge Date
• Working Days past discharge
• Summary of phone call
• Document in EHR (Centricity/Allscripts)
17. Phone Call - Metrics
• Number of eligible patients contacted
• Number of tries to contact patient
18. Transition of Care Clinic
Admission
Pre
Discharge
Day
Discharge
Follow Up
Call
Transition
of Care
Clinic
Transition
to PCP
19. Transition of Care Clinic – Part 1
Transitioning to PCP
Clinical Status Education
Provide
needed
education
MedRec
Update EHRUpdate EHR
Update PCP
Update
Consultants
MD or NPP MD, NPP, Pharm MD, NPP, Pharm MD, NPP, or RN
20. Transition of Care Clinic – Part 2
Transitioning to PCP
Follow Up
Confirm
Appointments
May need repeat TOCC
Visit for another E&M
Encounter if rapid follow
Up cannot be arranged
Service Type
E&M
(All pts)
TCM
Pts not eligible for TCM if
• In Global Surgical Period
• TCM Service within 30 days
• No phone call
• Discharged to SNF
• Visit not within 7 working
days of DC
TCM Patients will have two charges.
One for the E&M encounter and one
For Transition of Care Management
MD or NPP
21. TOCC – Documentation Required
• Phone Call Data
• Working Days post discharge
• Coordination of care
• Medication reconciliation
• E&M Documentation
• Document in Centricity/Allscripts
22. TOCC Billing
• E&M Visit (most if not all patients)
• TCM (for TCM eligible patients)
• E&M billed immediately
• TCM billed 30 days post discharge
24. TOCC Financial Estimates
• Half day of clinic 5 days per week
• 3-6 patients per day
• 50% qualify for TCM
• 2834-5668 RVUs/Year
• $162-324k/Year in charges
Patients/Week RVU/Week Charges/Week
15 54.5 $3117
30 109 $6234
25. Proposed TOCC Metrics
• Number of eligible patients served
• RVUs
• Revenue
• 30 Day Readmission rate (TOCC vs non-TOCC)
• HCAHPS
• PCP Satisfaction