Optimize Your Office Workflow to Fulfill Transition of Care Requirements to Meet the Transitional Care Program Guidelines.
To improve your office workflow and meet the guidelines of the Transitional Care Program, follow these steps:
- Assessment and Documentation: Start by carefully evaluating the patient’s needs and medical history as they transition between care settings. Ensure comprehensive documentation of their present health condition, prescribed medications, treatment plan, and any specific needs.
- Clear Communication Channels: Establish effective communication channels connecting the sending and receiving care teams. Integrate secure electronic health records (EHR) systems, telemedicine platforms, and encrypted messaging to enable smooth and secure sharing of information.
- Standardized Protocols: Develop and follow the standardized procedures for transferring patients during care transition. This checklist should include all necessary information transfer, ensuring that you do not miss any critical details.
- Care Coordination: Assign a care coordinator who is responsible to supervise the patient’s transition process. Ensure everyone knows their roles and responsibilities. The coordinator will facilitate communication and monitor progress.
- Medication Management: Establish an effective medication reconciliation process to avoid errors during transitions. Ensure that the patient’s medication list is correct and updated, and provide clear instructions for medication administration.
- Patient Education: Teach patients and caregivers about the transition process. Stress the importance of keeping follow-up appointments, taking medications, and following treatment plans. Give written instructions and resources for reference.
- Follow-up Appointments: Arrange follow-up visits with the receiving care team immediately after the transition. Ensure that the patient has a clear understanding of the time and location of these appointments.
- Cross-Continuum Collaboration: Promote collaboration between different care settings, such as hospitals, primary care practitioners, specialists, and rehabilitation centers. Regular interdisciplinary meetings can effectively address any challenges or difficulties and ensure a coordinated approach.
- Performance Monitoring and Improvement: Set up metrics to monitor the success of your transitional care initiatives. Consistently evaluate outcomes, patient satisfaction, and guidelines compliance. Utilize this data to identify opportunities and make necessary adjustments to your workflow or process.
- Training and Education: Train your staff regularly so they understand and can effectively implement the guidelines of the Transitional Care Program. Consistent training sessions can help keep all team members informed about best practices and any updates in care criteria.
Follow these steps to improve your office workflow and meet Transition of Care requirements and Transitional Care Management TCM guidelines (TCM medical abbreviation is Transitional Care Management). This will ultimately result in enhanced patient outcomes, decreased readmissions, and improved overall care coordination during crucial transitions.
How do you quickly find out the patient was discharged?
Follow these steps to determine patient discharge:
- Electronic Health Records (EHR) System: Use your institution’s EHR system to access real-time patient data. Search for the patient’s name or medical record number to check their current condition, such as discharge details and timestamps.
- Communicate with Nursing Staff: Contact the hospital staff, nursing staff, or specific unit regarding the patient. They can give immediately discharge information about the patient’s condition, including confirmation of their discharge, if applicable.
- Patient Tracking Board: If your institution utilizes a patient tracking board or electronic dashboard, it might display patient statuses, including discharges. Refer to this resource for the latest and most accurate information.
- Communication with Discharge Team: Contact the hospital discharge planning team for information sharing about the patient’s status and any relevant details. This interdisciplinary communication is key in obtaining correct information.
- Communication with Physicians: Get in touch with the attending physician or medical team responsible for the patient’s care. They can update you on the patient’s discharge status or provide guidance on where to find this information.
- Notifications or Alerts: Certain EHR systems have features that notify relevant staff when a patient is discharged. Check your notifications or alerts section to stay updated.
- Designated Discharge Area: Inquire at the designated discharge area or unit within the hospital. They can give details regarding recently discharged patients.
- Communication with Patient and Family: If appropriate, contact the patient or their family to ask about the discharge status. They may be able to confirm if the patient’s discharge status. Patient engagement is crucial in obtaining pertinent medical information.
- Collaboration with Colleagues: Work together with colleagues who may have participated in the patient’s care. They might have received discharge updates and can give valuable information.
- Shift Handover or Rounds: During the shift handover or rounds, ask your colleagues about the patient’s status or condition. They might have received updates throughout their shift.
Remember to always respect patient privacy and adhere to HIPAA regulations while seeking information about a patient’s discharge status. The approaches above will help determine the discharge status, and enable appropriate and continuity of care. It also assures appropriate placement in various community settings.
How do you get the information you need?
The ambulatory practice/clinic needs a workflow process to receive the discharge summary from the qualifying facility. This process should import the discharge summary into the EHR (Electronic Health Record) system of the practice.
Because popular EHR systems like CareEverywhere or CareQuality can share information, ambulatory providers can easily access the patient’s data. Both the information and the discharge date drive the complexity and correct time interval of the follow-up office visit.
TCM Code Requirements
Medicare transition of care requirements include several key elements:
- Initial Contact with the patient after discharge
- Face-to-Face Visit
- Transitional Care Management Services
- Level of Decision Making
- Medication Reconciliation
Initial contact required within 2 business days
To initiate TCM services, contact the patient within 2 business days after they leave the hospital or qualifying facility. This is to schedule a patient office visit. The type of visit depends on whether the reason for discharge was moderate or high medical complexity.
It does not require the office to schedule the visit within those 2 business days. However, an attempt to schedule the office visit needs to be at least done within this time period.
The face-to-face visit: complexity and timing
The face-to-face visit must take place within seven (7) calendar days of discharge if it is high medical complexity. The office visit CPT code to bill for a high complexity TCM visit is 99495.
The face-to-face visit must occur within fourteen (14) calendar days of discharge if it is moderate medical complexity. The office visit for CPT code to bill for a moderate complexity TCM visit is 99496.
You can also perform this post-acute care visit at the hospital, facility, or other post-acute care settings after discharge.
Face-to-Face Transition of Care requirements for documentation
Transition of care documentation requirements include the location, time, and date of the visit. Furthermore, record the findings and services provided, along with the qualifying provider’s credentials. It is also important to include the necessary findings to support the required medical decision-making level for the TCM code.
Who can bill TCM codes?
CMS transition of care requirements include a physician or qualified health care practitioner to bill for TCM codes. A qualified health care practitioner is a a mid-level, such as a Physician Assistant or Nurse Practitioner.
When to Bill TCM claim to meet the transition of care requirements ?
You can submit the TCM claim 30 days after the patient’s discharge date. This is applicable if the patient had a visit to the office within 7 to 14 days after discharge. The submission time of the claim depends on the complexity of their discharge, whether it was moderate or high. Additionally, it also depends on whether they received telehealth services during the month to prevent hospital readmission.
