Making sure your patients successfully transition from an acute care environment such as a hospital to home-based care can be difficult, especially if the patient or the care facility doesn’t alert you that he or she was admitted or is being discharged. To make the process less prone to mistakes or gaps, focus on improving these four areas:
1. Education. Explain to patients and their families how transitional care management benefits their long-term outcomes and why they should inform your practice when the patient goes to the hospital, share the primary care physician’s contact information with the acute care team, contact the practice when the patient is discharged, and come to the practice for a visit within 7 to 14 days after discharge.
2. Collaboration. Work with your acute care facility partners to obtain access to patient discharge summaries and other electronic records. Also, meet with hospitalists to establish collaborative processes for communicating patient discharge needs and summaries. Educate them about transitional care management and the importance of notifying the patient’s primary care team.
3. Workflow and protocol. Develop a staff training curriculum that covers the importance of transitional care management to patients and the practice, as well as how to document and code for transitional care management services. Also create a protocol that establishes a workflow and assigned roles and responsibilities for all team members in the practice.
4. Technology. Collaborate with your information technology team to make sure transitional care management documentation and codes are readily accessible in the practice’s electronic health record.
Read the full FPM article: “Transitional Care Management: Practice Processes for Your Practice.”
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