1. Description of Project
Developing a Process and Procedure to Increase the Number of Transition of Care Visits Completed in an Academic General Internal Medicine Practice Ryan Loeblich, Scott Joy, MD “
Aim Statement
Description of Project
Results to Date
The Medicare Transition of Care visit is underutilized in the United States
(only approximately 6% of eligible patients in the U.S. have been billed for a Transition of Care visit).
As a result, general internal medicine practices miss a financial opportunity
TOC 7d reimburses $235, TOC 14d $162,
a E/M visit reimburses $109, resulting in a difference of $53-$126/visit).
Our goal, capture all of the practice patients (new or established) who were admitted and discharged from our medical center.
The practice Care Manager was identified as practice champion for this process.
Admission were identified by:
Patient reports from inpatient services
notification from the medical center that identify patients who are currently in the ER of have been discharged
s from medical center care managers identifying patients who are in-house and who may be current patients of UPC or who may need PCP
Direct phone referral called in by referring ER physicians or floor physicians
When new or existing patients are identified as needing TOC, the care manager personally meets with the patient prior to discharge to identify TOC needs.
The patient is scheduled for a TOC call or
face-to- face (F2F) visit within 2 business days of discharge.
After receiving a 2 day TOC call, patients are also scheduled for a TOC F2F visit within 7-14 business days.
Between February 2016 and June 2016, 91 TOC patients were evaluated.
Of those 91 patients:
57% had a 2-7 day TOC F2F visit
13% had a 14 day TOC F2F visit
Overall, 70% had a billable TOC visit
Billing 52 patients for 7d TOC (52*$235) generated $12,220 revenue
Billing 12 patients for 8-14d TOC (12*$162) generated $1,944 revenue
Billing 64 patients at would generate only $6,976
Using TOC billing codes instead of generated an additional $7,188 for the practice
Develop a process and procedure to increase the number of Transition of Care visits completed in an academic General internal Medicine practice. 
Project Design
Develop a protocol to capture all practice patients who are discharged from an inpatient facility to insure that they have appropriate outpatient follow up within 14 days of discharge
Generate additional practice revenue by appropriate utilization of the Medicare Transition of Care visit
Define the role of the practice care manager in the Transition of Care process
A care manager led process can be developed to increase the number of patients receiving TOC visits. Practice revenue can increase by emphasizing TOC visits and processes.
Lessons Learned: