hospital discharge process overview
TRANSCRIPT
![Page 1: Hospital Discharge Process Overview](https://reader034.vdocuments.net/reader034/viewer/2022051318/5a6479857f8b9a76568b4609/html5/thumbnails/1.jpg)
Discharge Process
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
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Discharge Process Timing
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
Within 2 Working Days of Discharge
Within 7 Working Days of Discharge
30 Days Post Discharge
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Discharge Process
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
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On Hospital Admission – Part 1
Estimate LOS
Progress to Discharge
Anticipated Disposition
New SNF Placement
PT/OT Evaluation
Arrange SNF Placement
Home or Continued SNF
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On Hospital Admission – Part 2
Progress to Discharge
PT/OT
Order PT/OT Evaluation
Arrange for identified
needs
Quality Measures
Assess for QM Compliance
Address QM Needs
DME/O2
Order DME/O2 Evaluations
Arrange for identified
needs
Financial
SW/PCF Evaluation
Arrange for identified
needs
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On Hospital Admission - 3
Progress to Discharge
Financial
SW/PCF Evaluation
Arrange for identified
needs
Education
Assess for Educational
Needs
Address Educational
Needs
PCP
Determine if pt needs PCP
Refer to potential PCPs
Transportation
Determine if pt needs
transport
Arrange Transport
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Discharge Process
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
This step ideally starts on the pre-discharge day, but is often combinedWith discharge day tasks.
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Pre Discharge Day – Part 1
Discharge
Is Inpatient Therapy
Complete?
Disposition Needs
Needs Met and Arranged
Consultants
Follow Up Needed?
Arrange for Follow Up
Communicate with PCP
PCP NotifiedFlags/Phone
Arrange for Follow Up
Yes
Continue Inpatient Therapy
No
Process to Discharge
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Pre Discharge Day – Part 2
Discharge
Medication Reconciliation
MedRec Draft
Forms
Complete Forms
DC Summary
Dictate Draft
Face to FaceOut of Hospital DNRFMLADME Orders
Circle and signEHR MedRec
Quality Measures Recheck
Assess for QM Compliance
Address QM Needs
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Discharge
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
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Discharge Day – Part 1
Discharge
Medication Reconciliation
MedRecComplete
Update PCPForms
Complete Forms
Face to FaceOut of Hospital DNRFMLADME Orders
Circle and signEHR MedRec
Final ReviewUpdate
Consultants
Update DC Plans
Discharge Orders
Complete by 10AM
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Discharge Day – Part 2
Discharge
Need Labs for TOCC?
Order Labs
Discharge PtDC Summary
Complete DC Summary
Appropriate for TOCC?
Schedule for TOCC
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Follow Up Call
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
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Phone Call
Transitioning to PCP
Clinical StatusMedication
Reconciliation
Encourage taking
Medications
Education
Provide needed
education
Follow Up
Confirm Appointments
Phone call by hospitalist nurse, MD, or NPP
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Phone Call – Documentation Required
• Discharge Date
• Working Days past discharge
• Summary of phone call
• Document in EHR (Centricity/Allscripts)
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Phone Call - Billing
• None
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Phone Call - Metrics
• Number of eligible patients contacted
• Number of tries to contact patient
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Transition of Care Clinic
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP
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Transition of Care Clinic – Part 1
Transitioning to PCP
Clinical Status Education
Provide needed
education
MedRec
Update EHRUpdate EHR
Update PCP
Update Consultants
MD or NPP MD, NPP, Pharm MD, NPP, Pharm MD, NPP, or RN
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Transition of Care Clinic – Part 2
Transitioning to PCP
Follow Up
Confirm Appointments
May need repeat TOCCVisit for another E&MEncounter if rapid follow Up cannot be arranged
Service Type
E&M(All pts)
TCM
Pts not eligible for TCM if• In Global Surgical Period• TCM Service within 30 days• No phone call• Discharged to SNF• Visit not within 7 working
days of DC
TCM Patients will have two charges.One for the E&M encounter and one For Transition of Care Management
MD or NPP
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TOCC – Documentation Required
• Phone Call Data
• Working Days post discharge
• Coordination of care
• Medication reconciliation
• E&M Documentation
• Document in Centricity/Allscripts
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TOCC Billing
• E&M Visit (most if not all patients)
• TCM (for TCM eligible patients)
• E&M billed immediately
• TCM billed 30 days post discharge
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TCM Billing CodesCode Description RVUs Charge
99495 TCM, Moderate Complexity 2.11 $163
99496 TCM, High Complexity 3.05 $231
E&M Billing CodesCode Description RVUs Charge
99214 Office Visit, Est Patient, Level 4 2.21 $100
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TOCC Financial Estimates
• Half day of clinic 5 days per week• 3-6 patients per day• 50% qualify for TCM
• 2834-5668 RVUs/Year• $162-324k/Year in charges
Patients/Week RVU/Week Charges/Week
15 54.5 $3117
30 109 $6234
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Proposed TOCC Metrics
• Number of eligible patients served
• RVUs
• Revenue
• 30 Day Readmission rate (TOCC vs non-TOCC)
• HCAHPS
• PCP Satisfaction
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Transition to PCP
AdmissionPre
Discharge Day
DischargeFollow Up
Call
Transition of Care Clinic
Transition to PCP