Goppert Trinity Family Care Cindy McHenry, RN BSN Jennifer Tieman, MD Darren Presley, MD Research Family Medicine Residency

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Research Family Medicine Residency 36 Family medicine residents in Kansas City, Missouri 19 Faculty members, 50 clinic staff Community based residency We see critical to chronic patients at Goppert Trinity Family Care Medicaid, Medicare, Commercial and HMO Care provided by 3 teams and the Express Clinic

NCQA Certification NCQA Certification under the 2009 standards Will be up for renewal in 2015 During our application process we realized we needed to improve our discharge process After receiving our certification we began to remodel our medical home

Remodeling our Medical Home Hospital to Home (H2) Already had discharge process in place Needed to better transition the care of our hospital patients Formed multidisciplinary team to develop process

Discharge Process Before Certification Physician called office to schedule appointment If physician scheduled follow up appointment: Appointment information was given to patient on discharge paperwork If physician did not schedule appointment: Patient was instructed on discharge paperwork to contact the office

The Ideal Discharge Process Resident calls the clinic and schedules the appointment Appointment given to patient with clear discharge instructions Care Coordinator calls patient prior to appointment Reviews medications Confirms that all needs are taken care of Helps patient schedule any appointments with specialist Makes sure labs are done

Reality We have no care coordinator Just had staff lay offs No approval for additional staffing Patients do not know they have an appointment scheduled No clear discharge instructions Patient’s unclear about what medications they should be taking

Planning Stages Multidisciplinary team formed to discuss discharge process (resident, faculty, nurse, billing, medical records, front office) Team unsure of what current discharge process is Went to hospital and set in on rounds Began to develop process

Next Steps Discussed concept at CIC meeting Ideas from CIC taken to OPS committee (Operations Committee) Taken to Faculty meeting, Resident/Faculty meeting, nurse meeting and all staff meeting Staff Education

Discharge Process Post Certification: H2H Resident calls for follow up appointment before patient was discharged Patient sent home with discharge paperwork Patient Advocate obtain copy of discharge summary and contacts patient within 48 hours after discharge Opens a telephone encounter to document and assigns to: Nurse Social Worker Referral Clerk

Patient Advocate Received call from physician and schedules appointment Discharge information obtained from hospital Contacts the patient within 48 hours of discharge Creates telephone encounter and sends to lead nurse on the team the patient is scheduled with

Nursing Lead nurse on each team in charge of H2H Phones the patient within 48 hours of receiving the information Reviews medication with patient over the phone Answers any other questions the patient would have Reviews information with physician seeing the patient in clinic

Social Worker Phones the patient within 48 hours of receiving the information Helps patient with ride if needed Helps patient with funding of medication if needed Provides any additional resource the patient might need

Resident Residents coordinate discharge and follow up for hospital patients At time of discharge we determine if the patient will follow with GTFC A phone call is made to a coordinator at the clinic to establish a follow up appt Discharge medical reconciliation report is faxed to the clinic coordinator

Further Notification of Discharge

Physician Medicare started covering “Transition of Care” as a global fee in 2013 The codes cover the 30 day period after discharge from an inpatient setting (including LTAC, SNF, or rehab) Physician’s offices are now responsible for reaching out to the discharged patient, and the code covers certain non-face-to-face services such as communicating with home health agencies and reconciling medications

Information Sent to Create Encounter Initial Transitional Care Contact Sources of Information: [ ] Patient, family member, or caregiver (Name ) [ ] Hospital Discharge Summary [ ] Hospital fax [ ] Other Discharged from: on: Diagnosis/problem: Medication Changes: [ ] Yes [ ] No Medication List Updated: [ ] Yes [ ] No Needs referral or Lab: [ ] Yes, specify [ ] No Needs follow up appointment: [ ] Within 7 days of discharge (highly complex visit) [ ] Within 14 days of discharge (moderately complex visit) Appointment made for, with Additional information needed and requested: [ ] Yes – Specify [ ] No

At the Visit Patient’s with potentially life or limb threatening illness are seen within 7 days of hospital discharge All patients are seen with 14 days of discharge A standard order set with a transition of care plan is used to document the components of transitional care have been provided

Items to be Reviewed at the Visit Medication reconciliation: [ ] Medication list updated [ ] New medication list given to patient/family/caregiver Referrals: [ ] None needed [ ] Referrals made as noted Community resources identified for patient/family: [ ] None needed [ ] Home health agency [ ] Assisted living [ ] Hospice [ ] Support group [ ] Education program: ________________________________ Community resources identified for patient/family: [ ] None needed [ ] Home health agency [ ] Assisted living [ ] Hospice [ ] Support group [ ] Education program: ________________________________ Patient education handouts given about: Initial transitional care contact was made on ___/___/___ (see separate note)

Transition of Care Billing The Transition of Care code covers the global period of the first 30 days following discharge. The date of the claim must be the 30 th discharge day. Only 1 physician can bill this code, if more than 1 physician bills, only the first claim is paid No additional E&M services can be billed at the transition of care visit, but procedures can be billed separately

Patient Comments “Lisa helped me get medication I could not afford.” “Deb was very helpful. She made sure my FMLA paperwork was done correctly.” “I have been a patient of Dr. Rues for over 20 years. I really appreciated his nurse calling to check on me.”

What we have learned: the Positives……… Physician calls for appointment Appointment given in real time Patient sent home with appointment information Staff looks up discharge summary Phones patient within 48 hours after discharge Patient keeps appointment No show rate decreased to 13%

What we have learned : the not so positives………. It is hard to review medications over the phone. –Patient unclear of what they were taking before they were admitted –Patient unclear of what medication they were discharged with –Patient does not know the name of medications

Questions??