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

2. Disclosures ACTIVITY DISCLAIMER The material presented at this activity is being made available by the Society of Teachers of Family Medicine (STFM) for educational purposes only. This material is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed but, rather, is intended to present an approach, view, statement or opinion of the faculty that may be helpful to others who face similar situations. The STFM disclaims any and all liability for injury or other damages resulting to any individual attending this program and for all claims that may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented at these activities. Physicians may care to check specific details such as drug doses and contraindications, etc. in standard sources prior to clinical application. These materials have been produced. solely for the education of attendees. Any use of content or the name of the speaker or STFM is prohibited without written consent of the STFM. FACULTY DISCLOSURE The STFM has selected all faculty appearing in this program. It is the policy of the STFM that all CME planning committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Further Notification of Discharge

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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.”

23. 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%

24. 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

25. Questions??