1. Courtney selby, Pharm.d. arcare pgy1 Community pharmacy resident
Transitions of Care
Courtney selby, Pharm.d. arcare pgy1 Community pharmacy resident

2. Pharmacist Objectives
Describe Transitions of Care (TOC) and its impact on patient care.
Compare TOC among different healthcare settings, including hospitals, outpatient clinics, and community pharmacies.
Describe the billing requirements for TOC.
Identify gaps in the transition process and implement an intervention to bridge the gaps and improve the TOC process.

3. Technician Objectives
Define Transitions of Care (TOC) and its impact on patient care.
Compare and contrast TOC in various healthcare settings.
Identify potential gaps in TOC and discuss ways to better improve the process.

4. Disclosure
I have no financial relationships with any commercial interest(s) that provide healthcare goods and/or services to disclose.

5. Transitions of Care & Impact on Patient Care

6. Transitions of care is the movement of a patient from one healthcare setting to another, including outpatient clinics, skilled nursing facilities, and inpatient hospitals.
In this presentation, I will be focusing on acute inpatient and community outpatient settings.

7. 19.6 % longer hospital stay 50.2 % Rehospitalized within 30 days
How well were we doing?
19.6 %
Rehospitalized within 30 days
50.2 %
Had no bill for a physician’s office visit
Rehospitalized patients had a
A study published in 2009 with data collected on Medicare fee-for-service beneficiaries in discovered that almost 20% of patients discharged from a hospital were rehospitalized within 30 days. Of those, about 50% had no bill for a visit to a clinic between the time of discharge and readmission.
Patients readmitted within 6 months were also found, on average, to have a 0.6 day longer hospital stay than other patients with similar diagnoses
longer hospital stay
on average.
Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. "Rehospitalizations among patients in the Medicare fee-for-service program." New England Journal of Medicine  (2009):

8. 11 % 27 % less likely Developed an adverse drug event
How well were we doing?
11 %
Developed an adverse drug event
27 %
ADEs were preventable
less likely
Patients were
to experience
In another study published in 2005 on patients discharged from an academic hospital, 11% of patients discharged over a 3-month period were found to have had an ADE with 27% of those being preventable. They also discovered that patients were less likely to experience an ADE if someone had explained the side effects of their medications to them.
an ADE if they could recall having side
effects of medications explained to them.
Forster, Alan J., et al. "Adverse drug events occurring following hospital discharge." Journal of general internal medicine 20.4 (2005):

9. CMS Hospital Readmissions Reduction Program (HRRP)
Chronic obstructive pulmonary disease (COPD) acute exacerbation
Coronary artery bypass graft (CABG) surgery
Pneumonia
Heart failure (HF)
Acute myocardial infarction (MI)
Elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)
Background: Under the Affordable Care Act, the HRRP was established which requires decreased reimbursement for hospitals with high readmission rates.
Readmission Measures
Readmission: admission to a hospital within 30 days of discharge
Readmission Ratio > 1 indicates excess readmissions mission-reduction-program.html
What is being done to motivate us to improve care transitions?
“Readmissions Reduction Program.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 18 Apr. 2016,

10. Qualities of Effective Transitions of Care

11. Ineffective Transitions of Care
Communication Breakdowns
Patient Education Breakdowns
Accountability Breakdowns
“The need for a more effective approach to continuing patient care.” jointcommission.org, The Joint Commission, _Transitions_of_Care.pdf

12. Elements of Evidence-Based Transitions of Care Models
Multidisciplinary communication, collaboration, and coordination.
Clinician involvement and shared accountability.
Comprehensive planning and risk assessment during hospital stay.
Standardized transition plans, procedures, and forms.
Standardized training.
Follow-up, support, and coordination after the patient leaves a setting.
If a readmission occurs, find out why.
Evaluation.
“The need for a more effective approach to continuing patient care.” jointcommission.org, The Joint Commission, _Transitions_of_Care.pdf

13. Billing for Transitional Care Management (TCM) Services

14. Billing Components for Transitional Care Management (TCM) Services
From Inpatient to community setting
Face-to-Face Clinic Visit
2-Day Contact
Non-Face-to-Face Services
“Transitional Care Management Services.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 2016,

15. Questions?

16. References
1. Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. "Rehospitalizations among patients in the Medicare fee-for-service program." New England Journal of Medicine  (2009):
2. Forster, Alan J., et al. "Adverse drug events occurring following hospital discharge." Journal of general internal medicine 20.4 (2005):
3. “Readmissions Reduction Program.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 18 Apr. 2016, service-payment/acuteinpatientpps/readmissions-reduction-program.html.
4. “The need for a more effective approach to continuing patient care.” jointcommission.org, The Joint Commission, _Transitions_of_Care.pdf
5. “Transitional Care Management Services.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 2016, Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Transitional-Care- Management-Services-Fact-Sheet-ICN pdf