1. Utilization of Care Coordinators in Patient-Centered Medical Homes Elizabeth Beck MS(c), BSN, RN Mary Jo Welker, MD Randy Wexler, MD

2. Disclosures None

4. 2012 : Care Coordination team hired 2013 : PCMH recertification efforts begin 2014 : NCQA PCMH Level III status achieved (2011 standards)

5. Transitions of Care Readmission Reduction Task Force Nurse Executive Council Executive Committee Utilization Management Health Collaborative of Greater Columbus Ohio Department of Health

7. Transitional Care Management Transition from to: – Inpatient hospital to home/assisted living/rest home – SNF to home/assisted living/rest home – Inpatient hospital to rehabilitation Type of contact (within 2 business days of discharge): – In person – By phone – Electronically Service Provided (Physician or licensed clinical staff) - Direct contact to discuss care -Communication with home health agencies and other community services -Education of the patient/family/caretaker on self-management, and ADL’s -Assess/support treatment (including medication) adherence -ID relevant community resources -Coordinate access to needed post DC follow up services Contact Note (Description of what was discussed)

8. Transitional Care Management Billing Code: Once over the 30 day period. 99495 (moderately complex and seen within 14 days of DC) 99496 (highly complex and seen within 7 days of DC).

9. TCM Documentation Workflow

11. All cause 30 day readmissions

13. Additional Observations

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