Transitional Care Management Boosts Outcomes, Satisfaction 

This philosophy of taking more responsibility for the entirety of a patient's care is an ongoing emerging trend in medicine today and the basis of the move toward value-based payment.

Regardless of how much responsibility we think patients should take for their own care, the payment system for U.S. health care is moving in a direction where our responsibility for a patient's care does not end with our office or hospital encounter. It encompasses the care rendered to our patients by others in the ER, urgent care, hospital, subspecialist office and any other avenue of health care delivery, regardless of whether we were initially involved or not.

This is how we will be measured and paid in the future. Not by occurrence and episodic visits, but rather by the longitudinal care we provide our patients. Some may argue that newer practice models, such as direct primary care, may offer means to avoid this payment structure, and they may be right in some regard. But what can't be avoided, regardless of how we are paid for our services, is the potential improvement we can make in the lives of our patients by embracing a more comprehensive approach to care.

One small facet of this comprehensive approach is managing a patient being discharged from a hospital. During the past few years, my office has been actively working to improve the transition from hospital (or rehab) to home. It started as a slow endeavor, fueled by the promise of payment from Medicare for transitional care management (TCM) CPT codes.

First, we had to find out who was being discharged from the hospitals and rehab facilities, which is not an easy task. The area of the state where I practice has a health information exchange, so we started there. Unfortunately, it was not robust or reliable, but it gave us some names (although many times the information came a month after their discharge -- or later).

Next, we started contacting the seven hospitals in our area and the hospitalist groups that work there to ask for notifications when our patients were admitted or were to be discharged. We met with some resistance because we are not a hospital-affiliated practice but, again, it gave us some more names.

Then we contacted home health care agencies providing nursing and physical therapy services in patients' homes. They're the ones hospital discharge planners look to in an effort to reduce readmissions. Once again, it was not an overwhelming response, but it afforded us even more names.

At first, it appeared we were not making much of a dent in our endeavor, but with all our small successes in finding out when a patient was admitted and then discharged, we realized that we were actually becoming aware of the majority of our patients who had recently been admitted to one of those seven hospitals. We then made efforts to contact all the patients we knew about by phone (within two business days, if possible, for TCM billing to be applicable) to schedule follow-up visits in our office if appropriate (within seven to 14 calendar days if we were to utilize a TCM code).

In addition to scheduling, our office contact also reviewed the medications they were prescribed upon discharge and checked if other needs or follow-up were required. Additionally, they would then contact the facility from which the patient was discharged to obtain discharge notes, test results and summaries. And although not every discharged patient needed or desired this service, most of them appreciated the call and the show of dedication to their care by their family physician's office.

When a patient did follow up with an office visit, it provided an opportunity to explain to the patient and their caretakers what had actually transpired during their hospitalization (believe it or not, many have little understanding about their illnesses) and meet their care needs by arranging home services, assisting in scheduling subspecialist follow-up appointments and following up on testing performed prior to discharge.

As we tracked our successes, we noted a decrease in our hospital readmission rate, a small increase in Medicare payment, improved communications with outside organizations and greater patient satisfaction. I also found an unexpected benefit -- an improvement in my staff's job satisfaction. They felt more proactive in caring for our patients. They took ownership and pride in providing care to our patients as part of a team. Not only did they become endeared to our patients, but the patients became endeared to them, too.

Our efforts continue to be well received by both patients and staff. We continue to attempt to improve the longitudinal care of our patients -- more than just what is provided in and through my office. To that end, we have since expanded our services to include not only TCM, but also other care management services, spearheaded by our dedicated care manager. We are trying to be innovative and on the cusp of the modern delivery of medicine in a fashion we (clinicians and staff) feel comfortable providing. We are acutely aware of how the practice of medicine is changing, and we are positioning ourselves to be ready for anything that the future may bring.

Marc Price, D.O., is the owner of Family Medicine of Malta, a small, progressive group practice in Malta, N.Y. He also holds the title of assistant clinical professor of family and community medicine at Albany Medical College in Albany, N.Y.