Discharge Process

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

Discharge Process Timing

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

Within 2 Working Days of Discharge

Within 7 Working Days of Discharge

30 Days Post Discharge

Discharge Process

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

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

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

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

Discharge Process

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

This step ideally starts on the pre-discharge day, but is often combinedWith discharge day tasks.

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 NotifiedFlags/Phone

Arrange for Follow Up

Yes

Continue Inpatient Therapy

No

Process to Discharge

Pre Discharge Day – Part 2

Discharge

Medication Reconciliation

MedRec Draft

Forms

Complete Forms

DC Summary

Dictate Draft

Face to FaceOut of Hospital DNRFMLADME Orders

Circle and signEHR MedRec

Quality Measures Recheck

Assess for QM Compliance

Address QM Needs

Discharge

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

Discharge Day – Part 1

Discharge

Medication Reconciliation

MedRecComplete

Update PCPForms

Complete Forms

Face to FaceOut of Hospital DNRFMLADME Orders

Circle and signEHR MedRec

Final ReviewUpdate

Consultants

Update DC Plans

Discharge Orders

Complete by 10AM

Discharge Day – Part 2

Discharge

Need Labs for TOCC?

Order Labs

Discharge PtDC Summary

Complete DC Summary

Appropriate for TOCC?

Schedule for TOCC

Follow Up Call

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

Phone Call

Transitioning to PCP

Clinical StatusMedication

Reconciliation

Encourage taking

Medications

Education

Provide needed

education

Follow Up

Confirm Appointments

Phone call by hospitalist nurse, MD, or NPP

Phone Call – Documentation Required

• Discharge Date

• Working Days past discharge

• Summary of phone call

• Document in EHR (Centricity/Allscripts)

Phone Call - Billing

• None

Phone Call - Metrics

• Number of eligible patients contacted

• Number of tries to contact patient

Transition of Care Clinic

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP

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

Transition of Care Clinic – Part 2

Transitioning to PCP

Follow Up

Confirm Appointments

May need repeat TOCCVisit for another E&MEncounter 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

TOCC – Documentation Required

• Phone Call Data

• Working Days post discharge

• Coordination of care

• Medication reconciliation

• E&M Documentation

• Document in Centricity/Allscripts

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

TCM Billing CodesCode Description RVUs Charge

99495 TCM, Moderate Complexity 2.11 $163

99496 TCM, High Complexity 3.05 $231

E&M Billing CodesCode Description RVUs Charge

99214 Office Visit, Est Patient, Level 4 2.21 $100

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

Proposed TOCC Metrics

• Number of eligible patients served

• RVUs

• Revenue

• 30 Day Readmission rate (TOCC vs non-TOCC)

• HCAHPS

• PCP Satisfaction

Transition to PCP

AdmissionPre

Discharge Day

DischargeFollow Up

Call

Transition of Care Clinic

Transition to PCP