II. Definition
- Transitions of Care
- Transitions into and out of health care facilities
- Example: Hospital discharge to Nursing Home
III. Precautions: Transitions of Care
- Transitions of Care are high risk periods
- Associated with increased medication errors
- Associated with 20% re-admission rate within 1 month of hospital discharge
- CMS will penalize hospitals and care systems for excess 30 day readmission rates
IV. Approach: Medication reconciliation common problems
- Discrepancies between pre-admission medications and those during hospitalization and then at discharge
- Medications started in the hospital that should have been discontinued at discharge (or with set end-date or taper)
- Chronic medications that require re-start after being held during the hospitalization
- Changes in medication doses, frequency/schedule or formulation
V. Approach: Labs and Diagnostic common problems
- Pending test results following hospital discharge (occurs in 40% of patients discharged)
- Important results that change therapy are found in as many as 10% of pending results
VI. Billing: Evaluation and Management Codes (E&M Codes)
- Code 99495: Moderately complex medical decision making
- Patient Communication within 2 business days of discharge
- Face-to-face patient visit within 14 calendar days
- Code 99496: Highly complex medical decision making
- Patient Communication within 2 business days of discharge
- Face-to-face patient visit within 7 calendar days
VII. Prevention
- Communication between hospital care team and the clinic care team (sign-offs)
- Schedule hospital discharge follow-up prior to the patient leaving the hospital
- Clinic staff (e.g. triage RN) to call patient within 2 days of leaving hospital
- Provider visit within 7-14 days of leaving the hospital
- Give patients their discharge summary from hospital to bring to their follow-up appointment
- Educate patients and families on condition-specific home monitoring and measures
- Example: Daily weights in Congestive Heart Failure and what abnormalities should prompt a call
VIII. Disposition
- Median time to fullow-up after discharge: 12 days
- Risk factors for follow-up no-shows and same-day cancellations
- Medicaid insurance
- Black race
- Long admissions >15 days
- Discharge to home with services or to facilities
- Factors that make follow-up more likely
- Age over 65 years
- Living more than 40 miles from follow-up clinic
- Discharge from subspecialty clinic
- Follow-up with subspecialty clinic (in contrast with primary care)
- References
IX. References
- (2015) Presc Lett 22(3): 17
- Abrashkin (2012) Mt Sinai J Med 79:535–44 [PubMed]
- Hesselink (2012) Ann Intern Med 157(6):417-28 [PubMed]
