1. Transitional Care Management – PDSA approach to implementing federal regulations Kristi Van Riper, MPH, CHES Pete Harper, MD, MPH

2. 2 2 Objectives Verbalize CMS Transitional Care Management requirements Explain 30 th day process built in our system Recognize EMR build needed for implementation Minneapolis/St. Paul – 4 residency clinics, underserved population and many interpreted visits; Epic is our EMR Objectives and a little about us

3. 3 3 Why are you here? Technical advice? How’d we do this in the big picture sense? Intro

4. 4 4 Mechanic and Tompkins wrote in 2012 about how Medicare claims data showed Medicare spent as much or more in the 90 post hospitalization as they did on the hospitalization. 1 In January, 2013, Medicare began paying for two new CPT codes (99495 and 99496). These two new codes now allow for reimbursement of the non-face-to-face care provided when patients transition from an acute care setting back into the community. Background 1 Robert Mechanic, M.B.A., and Christopher Tompkins, Ph.D., Lessons Learned In Preparing For Medicare Bundled Payments, N. ENGL. J. MED. 2012; 367:1873-1875 (Nov. 15, 2012).

5. 5 5 It’s really a simple process… Phone call within 2 business days of d/c. Clinic visit within 7-14 days of d/c. Bill out at 30 th day post-d/c.

6. 6 6 …like a little ant hill.

7. 7 7 Date of service for the new codes should be the 30 th day post-discharge. An E&M cannot be billed out if the TCM code is used. Medicare will only pay the first eligible claim if multiple providers are submitting claims. Medication reconciliation and management should happen no later than the face-to-face visit. A few complexities of these codes

8. 8 8 So it’s more like a mountain!

9. 9 9 Specialty vs primary care – hospital perspective One FM clinic to develop and pilot How are we going to do this?

10. 10 Multidisciplinary team Narrow focus Clinic patients seen on clinic’s hospital teaching service Non-negotiables from CMS Development phase

11. 11 Workflow

12. 12 Phone call templates Progress note templates SmartSet 30 th day note template EMR build

13. 13 SmartSet screenshot

14. 14 Call patient/research admissions Document 30 th day note Release the future order or change the level of service to the documented E&M 30 th day process

15. 15 It’s more like a mountain range!

16. 16 Discharge Notification Problem 1.Don’t know when someone is about to discharge Solution 1.Patient census list, InBasket messages, chief residents call

17. 17 Phone Call Problem 1.Incorrect phone number 2.Discharge to other locations 3.Can’t reach patient Solution 1.Hospital service identifies 2.Let staff know not going home 3.Try 3 times over 2 business days

18. 18 Visit Problem 1.Provider doesn’t know what TCM is 2.Provider dictates notes 3.Timeframe of visit 4.Scheduling Solution 1.Education 2.Use the SmartSet and note, but dictate portions 3.Patient choice 4.PCP, then hospital team, then PCP team

19. 19 Billing Problem 1.Not using SmartSet 2.30th day coverage Solution 1.Education 2.Train someone else to cover the process

20. 20 Success from the top of the mountain!

21. 21 Spread to other clinics BuildImplementSustain Copy/edit Tracking Follow-up meetings Spreadsheet

22. 22 METRICS

23. 23 April 1 – September 30, 2015 BethesdaBroadwayPhalenSmiley'stotal Patients2568419481615 Calls completed59%86%94%83%77% Visits completed57%64%85% 73% Claims submitted77%59%74%68%72% Readmitted9%12%18%23%14%

24. 24 No denials Many payers 200% more reimbursement when compared to Medicare E&M’s when averaging out payments Finances

25. 25 Dictating providers Discharge notification Provider education Staff love 30 th day process Calls appreciated and not “technical” Lessons learned

26. 26 Behavioral health involvement Additional phone call Hospital relationships Spreading outside our hospital services Enhancements

27. 27 Have you tackled this project? What lessons did you learn? Any tips/tricks for others to hear? What’s your experience?

28. 28 THANK YOU!