Standardizing Transitional Care Management in Primary Care

Author

Anna A. Michelson, The University of VermontFollow

Date of Publication

2024

Project Team

Erin Leighton, DNP, APRN, FNP-BC; Alison Bovee, MBA

Abstract

Purpose: Transitional care management (TCM) refers to care delivered in the first 30 days following hospitalization during which an individual is discharged from the acute care setting to their home in the community. The primary purpose of this project was to develop and implement an evidence-based transition of care protocol in the primary care setting. The secondary purpose was to provide resources and education for clinic staff. Primary care TCM encounters are reimbursed at a higher rate as they require additional non-face-to-face services than standard Evaluation/Management encounters. This project also explored the potential for increased clinic revenue through utilization of billing and coding for TCM.

Methods: A standardizable, evidence-based protocol was developed and implemented over a 3-month pilot phase. Independent review modules, in-clinic reference sheets with TCM practice guidelines, and new Epic templates were introduced to clinic staff. Epic admissions reports and chart review identified patient eligibility.

Results: In-network discharge reports in Epic were run three times weekly with set parameters to identify eligible individuals (N=16). These records (n=18 hospitalizations) were then reviewed.Seven TCM visits were completed and billed. Six visits were assigned Evaluation/Management coding, however, three of these visits met the TCM coding criteria and were not billed as such. The seventh visit was appropriately assigned TCM coding. Eight participants were lost to follow-up.

Conclusions: Improving care coordination from hospital to home is possible. This pilothighlighted that stronger care coordination may require expanding the reserve of clinic nurses or licensed clinical staff eligible to complete TCM encounters.

Document Type

Dissertation/Thesis

Recommended Citation

Michelson, Anna A., "Standardizing Transitional Care Management in Primary Care" (2024). College of Nursing and Health Sciences Doctor of Nursing Practice (DNP) Project Publications. 164.
https://scholarworks.uvm.edu/cnhsdnp/164