Transitional Care Management: There and Back Again... A Patient’s Journey

Life after a hospital stay can have a few trials and tribulations, just like a great work of fiction. However, the patient's story is still unfolding. With care coordination support from nurse care navigators, the patient can overcome these challenges and safely complete their journey back home. Nurse care navigators assist the most vulnerable patients as they transition from an acute care hospital to the community setting in which they previously resided. Without their support, many patients may not receive a post-hospital stay follow-up within two weeks of discharge. The purpose of this presentation is to demonstrate how good patient identification tools, efficient documentation workflows, and coordination with other teams can help other organizations grow their transitional care management (TCM) program.
The health system has 12 community hospitals. The physicians group has roughly 75 primary care practices located in multiple counties in Northeast Indiana. In 2022, transitional care management coded visits (CPT codes 99495 & 99496) totaled only 3,201. There was an opportunity to support patients as they transition from the hospital and increase utilization of these TCM CPT codes. Lack of awareness about the TCM program and its requirements was present among both providers and care team members. Standardization of the interactive outreach documentation, as well as the creation of a uniform provider encounter note, was needed.
A report was created within EPIC to list all patients discharged the day prior from one of the 12 acute care hospitals. Obstetric patients and those discharged to a skilled nursing facility or hospice were excluded from the report. A telephone encounter dot phrase was developed that included a standard list of assessment questions the nurses would ask the patients. We also collaborated with an EPIC physician builder to create a transitional care management encounter for the providers to utilize. We educated and trained both providers and care team members on the two new standard notes.
Through this work, we identified the importance of communicating and getting feedback from all stakeholders involved in the TCM process. This includes hospitalist/rounding nurses, schedulers, care team members, providers, TCM nurses, and patients. As patients have started utilizing more electronic messaging verses phone communication, we have stayed nimble by implementing an EPIC MyChart TCM questionnaire. The provider’s note was also built in such a way that it can automatically pull the required documentation elements (e.g., location of hospitalization, date of discharge, interactive contact date, community setting to which they are returning) from the nurse’s encounter, making it much easier for the providers. Year to date for 2024, the total number of post-hospital stay encounters coded for TCM exceeds 6,300! Not only have we increased the revenue for the organization, but we have also been able to advocate and support patients with medication and social needs who otherwise would have gone back to the ER, helping to reduce readmissions and overall cost of care.