Our all-geriatric medicine practice of five physicians, four nurse practitioners, a clinical pharmacist, a physician assistant, a practice manager, three licensed vocational nurses, a receptionist, a scheduler, two benefit coordinators, and six medical assistants serves a panel of 2,400 patients across 15 counties in south Texas. These patients may be admitted to or discharged from 15 hospitals within five health care systems.
Our practice experienced two significant problems related to transitions of care. One, many of our patients did not attend scheduled office visits after being discharged from the hospital and soon went to the emergency department or were readmitted. Two, our inability to access area hospitals' electronic health record (EHR) systems impeded continuity of care.
In team meetings, we systematically devised a process for addressing these problems. Using process improvement tools (e.g., Pareto charts and root cause analyses) to critique our existing TCM process, we developed insights that led us to make changes in four areas:
1. Education. We realized that many of our patients did not understand the importance of TCM. For patients and their families, we developed materials that emphasized how TCM benefits patients' long-term outcomes and explained why they should inform the practice when the patient goes to the hospital or other acute/post-acute facility, share the primary care physician's contact information with the acute/post-acute facility team, contact the practice the day the patient is discharged, and come to the practice for a visit within 7 to 14 days after discharge. We displayed posters detailing TCM services in patient waiting areas and examination rooms, sent out secure email messages via our patient portal, and distributed colorful flyers to our acute/post-acute facility partners to give to patients upon discharge.
2. Collaboration. We worked with the Office of Professional Services at each of our acute/post-acute facility partners to obtain access to patient discharge summaries and other electronic records for our care managers and key office staff. We have true EHR compatibility with one health system, but with the other systems, designated people in our practice have at least read-only access to patient records. We also met with each facility's hospitalist team to establish collaborative processes for communicating patient discharge needs and summaries. We then met with emergency department physicians to educate them about TCM and the importance of identifying and contacting the patient's primary care team. We gave them the names and contact information for each of our PCPs as well as a back-up telephone number for the practice in case they couldn't contact a PCP. Magnetic cards with TCM information and PCP names and contact information were also distributed to the teams in each facility. During conversations with these partners, we reminded them that Medicare levies financial penalties for excessive patient readmissions and that reducing those read-missions should be everyone's goal.
3. Workflow and protocol. We developed a staff training curriculum that covered the importance of TCM to patients and the practice, as well as how to document and code for TCM services. We emphasized that “discharge” as it relates to TCM may refer to discharge from an inpatient setting such as an acute care hospital, rehabilitation hospital, long-term acute hospital, or skilled nursing facility, even if the stay was just for observation, as well as from a partial hospital program, such as those treating mental health or substance abuse disorders, where the patient spends the day at the treatment center and the night at home. Discharge from these settings may necessitate the handoff of medical crisis management, a change in therapy, or management of a new diagnosis, and the practice must provide medication reconciliation and new or ongoing specialist consultation.
We also created a TCM protocol that established a workflow and assigned roles and responsibilities to all team members in our practice. We trained our staff and clinicians during regularly scheduled team meetings to use the protocol and reinforced its proper use in daily huddles. Here's how it works:
4. Technology. We worked with our information technology team to develop TCM templates in our EHR that physicians and staff can use at various steps in the process. For example, during the initial communication with a patient or caregiver after discharge, the template reminds us to ask about updated medication or durable medical equipment, home health needs, pending lab tests, consultations, care goals, how soon the patient needs to be seen, and any tests needed before the TCM visit.
We piloted our TCM approach with one hospital system in 2013 and evaluated its effectiveness by tracking patient attendance at TCM visits. We then correlated that attendance with patient outcomes. Here's what we found:
These benefits have not been without cost or effort, however. In our experience, practices face at least two potential challenges in implementing a TCM protocol. The first is resistance to change by some patients, staff, and acute/post-acute facility partners. The best way to overcome this is to engage all of these groups while developing the protocol, explain to partners how the protocol benefits them as well as patients, provide in-service training for staff, and recognize individual efforts by patients, practice staff, and partners.
Second, it takes considerable time to create the protocol and implement it. We estimate we spent at least 500 hours in weekly meetings and daily huddles to develop, refine, and sustain our present TCM protocol. By following our example, practices could invest less time. Once the protocol is created, the practice will spend additional time communicating with patients and partners about TCM, obtaining and reviewing patient records, and conducting the face-to-face visits with patients.
Although TCM requires a significant time investment, it will benefit your patients, partners, and practice by improving patient outcomes and experiences, reducing costs, and improving quality of care. These benefits may also help your practice obtain more favorable contracts. We have received value-based contracts from three payers because of our TCM approach.
We did not do a formal cost-benefit analysis, but we believe the positive outcomes of our TCM approach have more than compensated us for the time we invested in establishing it. The reimbursement and work relative value units (wRVUs) generated by TCM codes have certainly been higher than for our regular office visits.
Integrating a TCM process into your primary care clinic takes work. You can achieve it by engaging with your acute/post-acute facility partners' leadership and formalizing partnerships with those facilities, leveraging your local health system's strengths and shared resources, writing protocols that define TCM processes, cross-training team members in your practice, and educating patients and caregivers. This effort will achieve a comprehensive TCM program that improves patient outcomes, reduces readmissions, and enhances the quality and safety of patient care.