Transitions of Care

1. Transitions of Care Courtney selby, Pharm.d.arcare pgy1 Community pharmacy resident

2. Pharmacist Objectives • Describe Transitions of Care (TOC) and its impact on patient care. • Compare TOC among different healthcare settings, including hospitals, outpatient clinics, and community pharmacies. • Describe the billing requirements for TOC. • Identify gaps in the transition process and implement an intervention to bridge the gaps and improve the TOC process.

3. Technician Objectives • Define Transitions of Care (TOC) and its impact on patient care. • Compare and contrast TOC in various healthcare settings. • Identify potential gaps in TOC and discuss ways to better improve the process.

4. Disclosure • I have no financial relationships with any commercial interest(s) that provide healthcare goods and/or services to disclose.

5. Transitions of Care & Impact on Patient Care

7. How well were we doing? 19.6 % Rehospitalized within 30 days 50.2 % Had no bill for a physician’s office visit Rehospitalized patients had a longer hospital stay on average. Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. "Rehospitalizations among patients in the Medicare fee-for-service program." New England Journal of Medicine 360.14 (2009): 1418-1428.

8. How well were we doing? 27 % 11 % ADEs were preventable Developed an adverse drug event less likely Patients were to experience an ADE if they could recall having side effects of medications explained to them. Forster, Alan J., et al. "Adverse drug events occurring following hospital discharge." Journal of general internal medicine 20.4 (2005): 317-323.

9. CMS Hospital Readmissions Reduction Program (HRRP) • Background: Under the Affordable Care Act, the HRRP was established which requires decreased reimbursement for hospitals with high readmission rates. • Readmission Measures • Readmission: admission to a hospital within 30 days of discharge • Readmission Ratio > 1 indicates excess readmissionshttps://www.medicare.gov/hospitalcompare/readmission-reduction-program.html “Readmissions Reduction Program.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 18 Apr. 2016, www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html.

10. Qualities of Effective Transitions of Care

11. Ineffective Transitions of Care CommunicationBreakdowns PatientEducationBreakdowns AccountabilityBreakdowns “The need for a more effective approach to continuing patient care.”jointcommission.org, The Joint Commission, https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf

12. Elements of Evidence-Based Transitions of Care Models “The need for a more effective approach to continuing patient care.”jointcommission.org, The Joint Commission, https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf

13. Billing for Transitional Care Management (TCM) Services

14. Billing Components for Transitional Care Management (TCM) Services From Inpatient to community setting “Transitional Care Management Services.”CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 2016, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

15. Questions?

16. References • 1. Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. "Rehospitalizations among patients in the Medicare fee-for-service program." New England Journal of Medicine 360.14 (2009): 1418-1428. • 2. Forster, Alan J., et al. "Adverse drug events occurring following hospital discharge." Journal of general internal medicine 20.4 (2005): 317-323. • 3. “Readmissions Reduction Program.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 18 Apr. 2016, www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. • 4. “The need for a more effective approach to continuing patient care.” jointcommission.org, The Joint Commission, https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf • 5. “Transitional Care Management Services.” CMS.gov Centers for Medicare & Medicaid Services, U.S. Centers for Medicare & Medicaid Services, 2016, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf