Transitions of Care Innovations in the Medical Practice Setting

Transcription

1 Transitions of Care Innovations in the Medical Practice Setting Linda Wendt, System Director of Quality- UnityPoint Clinic Sheila Tumilty, Senior Project Manager- UnityPoint Clinic Session Objectives After this session, attendees will be able to: 1) Understand the basics of the Transitional Care Management (TCM) code and possible impact on preventing readmissions. 2) Utilize a collaborative model in implementing Care Transitions work 3) Apply benefits of Adaptive Learning in pilot sites 2 1

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3 UnityPoint Clinic Who are We? UPC Overview Employees 2,717 NPs 112 PAs 69 Physicians 452 Clinics 125 Patient Visits 1,789,581 Total 514,634 Unique 5 System Initiatives Supporting Transitional Care Advance Medical Team (High risk patients, multidisciplinary team approach, Care Navigators) Patient Centered Medical Home (Redesigning care delivery, team based concepts, Care Coordinators) Medication Therapy Management (PharmDs) Behavioral Health (Co-location in Primary Care) 6 3

4 Care Coordination Video-Waterloo 7 Focus on connecting patients to their PCP 60.0% Follow Up Appointment within 7 Days Post Discharge Percent of Patients Seen 50.0% 40.0% 30.0% Total Region 1 Region 2 Region 3 Region 4 Region 5 Linear (Total ) 20.0% 8 4

5 Tracking Readmissions 25.0% 30 Day Readmission Rate by Region Initial Discharge Dates: December November 2013 Readmission Attributed to the Primary Care Phyisician listed on Initial Discharge 20.0% Readmission Rate 15.0% 10.0% 5.0% 0.0% 9 Transitional Care Management: Overview and Keys to Successful Implementation 5

6 Overview What s all the fuss about? What is transitional care management (TCM)? What is the medical evidence supporting such visits? What are the elements included in the new transitional care management codes? Putting the elements together. Exceptions to billing the TCM. Overview of the current state of TCM and expected utilization. 11 The Current State: Transitions of Medical Care Between Hospital and Home Nationwide: At least 27-35% of readmissions are preventable Nationwide: % of Patients Are Readmitted To a Hospital Within 30 Days. Nationwide: Average Number of Patients Who See A Physician Within 30 Days After Hospitalization: < 50% 12 6

7 The More Ideal State: Simplified Transitions of Medical Care Less of this or at least better integrated care. More or at least appropriate amounts of this based on needs of patient and family. Supported by this.. 13 TCM Code Overview Introduced by CMS effective 1/1/2013 Goal: Further improve care management for a beneficiary s transition from the hospital to the community setting, ultimately reducing readmissions Created to better reimburse non face-to-face care coordination that should occur outside of an office visit Other payers are recognizing TCM codes WARNING: CMS (and others) HAVE DETERMINED THAT POORLY COORDINATED, NON-MANAGED AND NON-PATIENT CENTRIC TRANSITIONS OF CARE CAN BE DANGEROUS TO YOUR HEALTH! 14 7

8 TCM Code Overview Total RVU s, 2.11 Work RVU s (CMS pays about $163) Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Medical decision making of at least moderate complexity during the service period. Face-to-face visit, within 14 calendar days of discharge.* Total RVU s and 3.05 Work RVU s (CMS pays about $231) Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Medical decision making of at least high complexity during the service period. Face-to-face visit, within 7 calendar days of discharge.* The same code applies to new and established patients. 15 TCM Code Overview Code Components: The Face to Face Visit There is nothing intrinsically different about the face to face visit with the patient which sets it apart from other post-discharge follow-up visits, except that it is one of the included components within the context of the other parts of transitional care management. Payment for non-face-to-face care management services is bundled into the entire transitional care management code which includes a face-to-face visit and contact within 48 hours. 16 8

9 Documenting All the Elements Using a Checklist Link: nts/prac_mgt/codingresources/tcmworksheet.par.0001.fi le.dat/tcm30day.pdf 17 Utilizing a Collaborative Model in Care Transitions Work 9

10 Development of Regional Care Transitions Work Groups Team Selection Senior Leader & Physician Engagement Cross Continuum Partnerships Team Facilitation Collaborative Model 19 Care Transitions Work Groups Adaptive Learning Benefits Opportunity to See Gain observational skills Builds trust within a team Realize failure is acceptable Testing multiple changes at once Builds interest in learning Ideal patient centered care Introduction to PDSA Adaptive Design, Ideal Care are trademarks of John Kenagy MD 20 10

11 Care Transitions Work Groups IHI Clinical Office Practice How-To-Guide Statewide Alignment Phased Approached Structure 21 Phases of the Work Phase I: Prior to the visit Phase II: During the Visit Phase III: At the Conclusion of the Visit 22 11

12 Care Transitions-Phase I In 2013 Project Managers successfully deployed Phase I with the development of TCM processes to all primary care offices within UnityPoint Clinic Key requirements for billing the code: Follow up visit within 7 days to bill a high or moderate complexity Follow up phone call within 2 business days Review of the discharge documents **All in alignment with Phase I reducing readmissions work 23 TRANSITIONAL CARE MANAGEMENT (TCM) March 2013 Committes Formed for Deployment Pilot Sites Selected April-May 2013 Workflows Developed Testing & Validation in Pilot Sites June- August 2013 Spread Plans Developed Spread to All Primary Care Sites 24 12

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14 27 TRANSITIONAL CARE MANAGEMENT (TCM) Tools for Successful Implementation Daily Discharge Reports Phone Call Templates (paper & EMR) Talking Points for Phone Call Provider Templates (EMR) FAQ s on TCM Audit Tools for Project Managers 28 14

15 TCM Pilot testing in Region 1 in March. Rapid deployment in other regions in April, May, and June. TCM Codes- Billed Number billed 100 Region 1 Region 2 50 Region 3 Region 4 0 Mar Apr May Jun Jul Aug Sep Oct Nov Dec 29 PHASE II: DURING THE VISIT Implemented during the roll-out of TCM through the use of the documentation in the provider template Sharing of pertinent information regarding the patient amongst staff and providers through a huddle, prior to seeing the patient Assuring the patient has an understanding of why they were in the hospital or the ED Assessing whether the patient has an understanding of meds, what they are taking them for, how often Setting goals for the management of the patient s illness Teachback Medication Reconciliation Readmission Opportunities 30 15

16 Care Transitions Work Groups Benefits Creates a better care coordination team as we become familiar with each other and are working together toward a common cause Generates better communication and understanding between different departments in regards to the work being done around patient care Gives you the ability to prioritize and focus the work in areas that make the most impact 31 Next Steps Further identify focus areas throughout the care continuum with transitions work groups Spread Adaptive Design, PCMH and AMT to UnityPoint Health Clinics Continue to provide the Best Outcome for Every Patient Every Time through care coordination 32 16

17 Contact Information Linda Wendt, RN, BA, CPHQ System Director of Quality Administrative Lead- Patient Centered Medical Home Sheila Tumilty Senior Project Manager Quality 33 Transitions of Care Innovations in the Medical Practice Setting Appendix Slides

18 What s the Evidence that Transitional Care Management Reduces Readmissions? Project RED (Re-engineered Discharge): 30% reduction in re-hospitalization within 30 days. (RR= 0.695; 95% CI ; p=0.009). Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine. 2009;150(3): Phillips et al, 2004: 18 study meta-analysis found an overall 25% reduction in rehospitalizations when comprehensive discharge planning post-discharge support was utilized. (RR 0.75; CI ; NNT 12). Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with post-discharge support for older patients with congestive heart failure: A meta-analysis. Journal of the American Medical Association. 2004;291(11): Home Health with PCP: 2 Studies on intensive early home health visits in the immediate post-hospitalization period reduced readmissions in patients with heart failure (39.4% vs. 15.8%, p<0.001), but not those with insulin dependent diabetes. Another similar study showed a reduction in readmission by 2.6% over a 6-month period. Rogers J, Perlic M, Madigan EA. The effect of frontloading visits on patient outcomes. Home Healthcare Nurse. 2007;25(2): Crossen-Sills J, Toomey I, Doherty M. Strategies to reduce unplanned hospitalizations of home healthcare patients: A STEP-BY-STEP APPROACH. Home Healthcare Nurse. 2006;24(6): This is a very small sample of studies that show a relationship between coordination of care and transitional care management between hospital and home and a reduction in readmissions. Many other studies conducted and ongoing in this area. 35 TCM Code Overview Code Components: Non Face to Face Services Non face-to-face services provided by clinical staff, under direction of physician or other qualified health care professional, may include: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Communication with home health agencies and other community services utilized by the patient Patient and/or family/caretaker education to support selfmanagement, independent living, and activities of daily living Assessment and support for treatment regimen adherence and medication management. Identification of available community and health resources. Facilitating access to care and services needed by the patient and/or family

19 TCM Code Overview Code Components: Non Face To Face Services Non face-to-face services provided by the physician or other qualified healthcare provider may include: Medication reconciliation (can be done by staff, reviewed by clinician) Must be completed before face to face office visit. Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents). Reviewing need for or follow-up on pending diagnostic tests and treatments. Interaction with other qualified health care professionals who will assume or reassume care of the patient s system-specific problems. Education of patient, family, guardian, and/or caregiver. Establishment or reestablishment of referrals and arranging for needed community resources. Assistance in scheduling any required follow-up with community providers and services. 37 TCM Code Overview Other Notes: Payable only once in 30 days following DC, per patient per DC, to a single physician or non-physician practitioner (First Claim Policy) Billable only at 30 days post DC or thereafter If patient admitted again, the time starts over. Physician can bill an office visit code if face to face occurred. Who can report? PCPs, specialists who provide all services, non-physician qualified healthcare professionals (NP, PA, CNS, CNMW) Does not have to be primary care physician or patients primary physician, however. Physicians should not undertake TCM services unless they are capable and willing to assume comprehensive responsibility for a patient s care during the period of the service Physicians can report both the discharge management code and a CPT TCM code Physician who reports a global procedure cannot also report TCM service Non face-to-face services should be conducted by someone who works with the patients clinician and is under the supervision of that clinician. 20% Beneficiary co-insurance applies 38 19

20 TCM Code Overview Code Components: Submitting the Bill TCM visits should be billed under the PFS after the conclusion of the service and should be submitted by only one individual and only once per patient, at 30 days post-discharge or thereafter. The place of visit used with the code submission should be the site of the face-to-face visit. FQHC s and RHC s may not bill the TCM code but may bill as usual for a face-to-face visit. If a patient is re-admitted prior to 30 days, the provider can still bill the code as long as 30 days have transpired and include the time following the second discharge. Otherwise, the provider can bill an office visit for the first post discharge work and then re-start another 30 day service period and bill a TCM code. If the beneficiary passes away during the 30 day period, a TCM code cannot be billed. 39 The following are a list of service codes that may not be billed during the 30 day period when billing a transitional care management code. Care-plan oversight (99339, 99340, ), Prolonged services without direct patient contact (99358, 99359) Anticoagulant management (99363, 99364) Medical team conferencing codes ( ) Patient education and training codes( , 99071, 99078) Telephone based services ( , ) End stage renal disease (ESRD) services ( ) Online medical evaluation services (98969, 99444) Preparation of special reports (99080) Analysis of data (99090, 99091) Complex chronic care coordination services (99481X X), Medication therapy management services ( ) 40 20