Abstract W P366: Increasing Utilization of Transitional Care Management (TCM) codes for Post-acute Stroke Care

Background and Issues: Stroke patients discharged home often are medically complex with decreased functional independence, especially during the initial transitional period after discharge. The Centers for Medicare and Medicaid Services has set transitional care requirements with new TCM coding that includes a 48 hour phone call from a licensed health professional and provider visit within 14 days after discharge. Process improvement methods can help determine the necessary staffing in order to efficiently meet these guidelines and increase utilization of these codes. Purpose: To review our post stroke transitional care program for TCM code utilization before and after addition of an RN to perform the follow-up phone calls. Methods: We performed a retrospective review of our hospital-supported transitional stroke care program. Our program initially consisted of 2 NPs on rotating schedules between inpatient service and outpatient ambulatory clinics to provide continuity of care during the transitional period after discharge, followed by 2 week hospital follow up visit focused on stroke education, caregiver support, recovery, and complications. The 2 nd phase included NPs performing high risk 48 hour phone calls after discharge thus allowing utilization of TCM codes. The 3 rd phase included addition of an RN to perform 48 hour phone calls and coordinating care between discharge and the stroke NP clinic visit. To assess the increased benefit of adding an RN for phone calls, we searched our EMR for TCM codes during the 3 month period before and 3 month period after RN phone calls were performed (February 2014 through July 2014). Results: A total of 95 patients were discharged home with a stroke or TIA in 6 months. In the first 3 months, 9 TCM codes were utilized. The last 3 months after the RN focused on 48 hour calls, 20 TCM codes were utilized. Conclusions: The a ddition of an RN to help provide 48 hour phone calls to patients after discharge increased the utilization of TCM coding. Further assessment of our transitional care program and use of TCM coding will be focused on effectiveness of decreasing readmission rates and improving outcomes.