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Seven steps for managing transitions of care


While it is easy to feel powerless during care transitions and difficult to influence the processes and handoffs taking place outside your practice’s walls, don’t despair: Here are seven steps to build a rigorous transition of care process that can make a difference in how your practice operates.


While it is easy to feel powerless during care transitions and difficult to influence the processes and handoffs taking place outside your practice’s walls, don’t despair: You can build a rigorous transition of care process that can make a difference in how your practice operates.

Ideally, a care transition is a value-based, patient-centric event that does not disrupt the continuity of care.


Unfortunately, the process of moving patients from one setting to another, or transferring their care between providers, is an uncertain process. All too often delays, disruptions, and miscommunications lead to confusion, unnecessary costs and care, and, ultimately a great deal of frustration for patients and physicians alike.

The most frequent pitfalls in the transition process are:

  • poor communication between facilities and providers;

  • insufficient engagement in the transition process by patients and caregivers; and

  • failure by the local medical community to demand and clearly designate strict accountability for managing the transition. 

Here are steps your practice can take to improve care transitions for your patients.

1. Formalize your inbound patient referral process

Your electronic health record (EHR) may have tools to help communicate information you want to know about a new or referred patient, but don’t expect any system to perform the whole job by itself.

List the information you need to manage the care of patients you accept from other providers. If your EHR doesn’t provide an electronic consult request form, create one. Make sure that the form is in a format the transferring facility or provider can easily view, such as a text file or Excel spreadsheet. Even a hard copy printout will work. Design it in the form of a checklist of all critical elements-patient history, records, medications, and other information-that you want on hand either before or during the patient’s visit. If you want patients or referring providers to send more information, make sure to also tell them when you need the data.


Develop a timeline that runs from when a patient referral is made to the appointment day. Don’t forget to include adequate time for your staff to process the referring physician’s data if it is not in a format that can be transferred directly into your EHR.

The time you spend to establish standard protocols for the transition of patients from other settings into your practice will be well worth it to you, your patients, and your support staff.

2. Focus on the logistics of external referrals

When you refer patients for care outside of your office walls, focus on the logistics. How does the information travel from your practice to the physicians, hospitals, or those other resources involved in your patient’s care? Importantly, understand the information that the other provider or facility has requested to always receive-hold staff accountable for always including that information when a patient’s records and treatment plan are transferred.

Likewise, develop processes to ensure that your practice’s contact at the receiving institution knows what information you want regarding your patient’s condition and the current course of his or her care, and when you need it.

Assign and accept accountability. Identify the key facilities in the community that your patients use for care. Approach each of these facilities to discuss patient care hand-offs-both their needs and yours. For example, if you refer a patient for a magnetic resonance imaging procedure, determine:

  • what the imaging center needs from you in order to make the patient’s appointment;

  • how soon  the patient can be scheduled for an appointment;

  • how and when the information - the image and accompanying interpretation, in this case - will be sent to your practice;

  • what the staff at that facility likely tell your patient about when and how the results will be reported to the patient; and 

  • who is responsible for getting in touch with you and what the protocols are for the communication of critical results

Provide a telephone number or a secure, web-based email box for physicians, the hospital’s case managers, or discharge planning team members to reach you.

You may want to know about the facility’s internal handoffs of care during your patient’s stay, or just to learn of certain major events. This direct channel helps to avoid delays, and, importantly, prevent no-shows when a follow-up visit is to be scheduled with you.

Many medical practices establish a protocol for their nursing staff to call all newly discharged or transferred patients within 48 hours after the discharge. This valuable contact can clarify follow-up on care instructions, detect complications and, often, get a general sense of the patient’s immediate well-being.

3. Get paid

Streamlining the transition of care need not be an unreimbursed expense to your practice.

In 2013, two new Current Procedural Terminology (CPT) codes were introduced to cover transitional care management (TCM). The new codes are selected based on the complexity of the patient.


Importantly, the codes require you to communicate with the patient and/or caregiver (through direct contact, telephone, or electronically) within two business days of the patient’s discharge, and conduct a face-to-face visit within seven to 14 days post-discharge, depending on the patient’s complexity level.

Select the proper CPT code based on the level of medical decision-making and the timing of the face-to-face visit. The codes and descriptions are:

99495: Transitional care management services: Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least moderate complexity during the service period; and a face-to-face visit within 14 calendar days of discharge.

99496: Includes the above, and medical decision-making of high complexity and a face-to-face visit within seven calendar days of discharge.

Pay attention to what services may be performed by licensed clinical staff under the direction of the physician or other qualified health care professional. These include:

  • communication (direct contact, telephone, electronic) with the patient and/or caregiver regarding aspects of care;

  • communication with home health agencies and other community services utilized by the patient;

  • Education of the patient and/or family/caretaker to support self-management, independent living and activities of daily living;

  • Assessment and support for treatment regimen adherence and medication management;

  • Identification of available community and health resources

  • Facilitating access to care and services needed by the patient and/or family.

The codes are billable at the end of the 30-day period, can be used by only one physician or provider, and may be reported only once during the 30-day period, even if the patient is re-admitted.

While any physician or other qualified healthcare professional may use both the discharge code and appropriate TCM code, a TCM code cannot be used by a physician who also reports a service to the patient within a global period of 10 or 90 days.

4. Collaborate

Care transitions can be an opportunity for you and your practice’s care team to find common goals with the other physicians and facilities that provide care to your patients.

These goals can include:

  • educating patients about the care plan and the signs of a worsening condition,

  • offering patients clear instructions about follow-up care, and

  • identifying the resources the patient should contact with questions and concerns.


While you probably won’t be at patients’ bedsides when they are discharged, you’d still like to know what discharging physicians and facility staff communicate to the patients and their caregivers.

Look also to how the care team provides the information to the patient. Do instructions and other knowledge come in multiple formats such as printed hard copies, web-based information, and/or instructional videos? Do those materials seem like they would be understandable and engaging to your average patient and his or her caregivers?

It’s no longer adequate to wait and hope  that the patient absorbs the “right” information to keep him or her healthy; engage with providers and caregivers across the care continuum to ensure that care transitions are managed effectively.

5. Improve performance

Hospital readmissions are prime targets for the outcomes improvement and cost containment efforts of Medicare and many other public and private insurers.

One in five patients discharged from the hospital to home experiences an adverse event-an injury related to medical management, not the underlying disease- within three weeks of discharge. Researchers also concluded that 66% of these events were drug-related adverse events, many of which could have been avoided or mitigated.

Whether or not bundled payment or other new reimbursement strategies have taken hold in your market, you still have much to gain by working with your local hospital to reduce the frequency of readmissions by your patients.

Efforts to reduce hospital readmissions through better care coordination among providers often target specific types of patients, such as those with ambulatory-sensitive conditions that can be optimally managed in the outpatient setting (such as diabetes or asthma), or patients who are at high risk (such as patients with chronic obstructive pulmonary disease or congestive heart failure).

6. Focus on prevention

Learn about your own readmissions before investing in more prevention techniques such as care and case outreach, 24-hour nurse triage hotlines to answer patients’ questions, and patient education materials that are appropriate to the patient’s education level, language, and culture.

Those all have potential, but first, look for patterns in your readmitted patients. Key points to determine and assess are the readmitted patient’s diagnosis, last visit date with your practice, and most recent communication with your practice-even the time of day and  day of the week.

Once you have your data, look for opportunities to prevent future readmissions. After addressing the communication roadblocks or accountability failures within your practice, look for opportunities to collaborate with other providers in the community. Addressing these barriers creates value for patients, and the healthcare system.


7. Form a Patient-centered Medical Home

To take the effort a giant step further, primary care and other types of medical practices are eying the medical home concept.

Studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reductions in health disparities  between disadvantaged and more socially advantaged populations.

The medical home’s focus on patient advocacy can provide the attention needed to smooth transitions of care. Even if your practice chooses not to seek formal recognition as a medical home, the medical home concept provides food for thought and, possibly, a lead on changes you can make within your practice to improve the care transition process. 


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