Maturity Models

Streamlining Transitional Care Management Workflows

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Jefferson Health’s goal was to prioritize transitional care management; however, they recognized that the transition from inpatient to outpatient care is not a seamless one if the appropriate safety measures and protocols are not in place. Although patients are encouraged to receive care within the Jefferson Health system, nearly half of patient discharges occur from nearby institutions in Philadelphia, the nation’s fifth largest urban area. These transitions put patients in a particularly vulnerable position and increase the risk of adverse events, readmission and medication errors, as well as potentially creating care gaps.

A recent study demonstrated that Medicare Transitional Care Management (TCM) services were associated with a reduction in mortality and total Medicare costs. However, the same study also showed that Medicare TCM code use was particularly low in most areas, indicating a significant opportunity for improvement for the health system.

Jefferson Health’s primary care practices serve over 80,000 patients and conduct around 8,000 hospital discharges per year. Historically, about one-third of these patients were contacted post-discharge, with a lack of workflow consistency throughout the process. Recognizing the need for improvement, Jefferson Health worked to implement a program that would support more efficient workflows.

Prioritizing Transitional Care Management

Jefferson Health convened an interdisciplinary team that included information systems, technology and care coordination expertise to implement a Medicare TCM program.

The program included a process for interactive contact with the beneficiary within two business days of discharge and follow-up interventions that can be conducted digitally, like medication reconciliation, home care management, and tests and appointments. In-person visits are scheduled within 7–14 days on a case-by-case basis. Upon implementation in 2017, many of the primary care practices within Jefferson Health enrolled in the Centers for Medicare & Medicaid Services Comprehensive Primary Care Plus (CPC+) program, which provides additional funding to strengthen primary care. Funds from this program expanded existing care coordination programs to develop a structured transitional care management program.

Using a primary care roster obtained from the EHR, a central team received notifications of all hospital and skilled nursing facility discharges in the Philadelphia area from the regional health information exchange (HIE). These patients were then stratified into two groups for lower and higher complexity cases. Within two days of discharge, a medical assistant health coach contacted lower complexity patients, and a registered nurse care coordinator contacted higher complexity patients. Both teams used a structured script for their phone calls, recording discrete data into standardized forms in the EHR system. They addressed medication reconciliation, home care services and follow-up testing as needed, and scheduled patients with their primary care practices within a week. At the follow-up appointment, clinical decision support tools in the EHR alerted the provider that a patient qualified for Medicare TCM billing, provided a structured note template and recommended proper billing codes.

As a result of these efforts, Jefferson Health increased post-discharge patient contact from 35% to over 80% of patients within one year of implementing the transitional care management program. Additionally, the organization’s participating primary care practices exceeded program requirements to contact over 75% of patients after hospitalization. By meeting the requirements of their CPC+ program, Jefferson Health also avoided a potential penalty of $2 million for care coordination payments.

Electronic Medical Record Adoption Model Stage 7 Validation

HIMSS is pleased to recognize Jefferson Health for their HIMSS Electronic Medical Record Adoption Model (EMRAM) Stage 7 validation. The organization also validated Stage 7 on the HIMSS Outpatient Medical Record Adoption Model (OEMRAM).

“Jefferson Health’s use of technology yields many clinical improvements,” said Philip Bradley, regional director, North America, HIMSS Analytics. “By leveraging data analytics, Jefferson Health has realized $115 million in ongoing savings through operation improvements.”

“I used to spend entire patient visits trying to find records and decipher what happened in the hospital,” said Bracken Babula, MD, internal medicine physician and medical information officer, Jefferson Health. “Now when I see my patients after discharge, I know someone from the team has already called them, their records are available in the EHR or HIE, and I can spend the time actually addressing their healthcare needs and trying to avoid another hospitalization.”

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Updated February 21, 2020

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