Transitional Care Clinic: Making the Calls that Matter Most!

1. Transitional Care Clinic: Making the Calls that Matter Most! Michelle Wasko, MS, BSN, RN, NE-BC Lisa Merritt, BSN, RN, OCN May 2, 2014

2. The Ohio State UniversityComprehensive Cancer Center James Cancer Hospital and Solove Research Institute • Located in Columbus, Ohio and 1st dedicated cancer hospital in the Midwest. • One of 10 freestanding cancer hospitals in the nation. • Designated as a Comprehensive Cancer Center (CCC) by the National Cancer Institute (NCI). • Member of the National Comprehensive Cancer Network (NCCN). • Currently a 228 bed hospital with a 24 bed blood and marrow transplant unit, 26 basic research labs and multiple ambulatory clinics on campus and through out the community. • Designated as a Magnet Hospital in 2013. • Future growth- A new 21 level James Cancer Hospital will open in December 2014. Columbus, Ohio 2

3. Division of Hematology 25 Attending Physicians 18 Advanced Practice Providers Average 275 Inpatient Admissions each Month Average 1,725 Outpatient Visits each Month Inpatient Services Include: • BMT • Hem 1 • Hem 2 • Hem 3 • Hem 4

4. Transitional Care Clinic: Making the Calls that Matter Most! Post Discharge Management

5. Transitional Care Clinics • In 2013 Medicare implemented two new billing codes for transitional care management • 99495 (basic) and 99496 (complex) • In order to bill under either code, the following needs to occur: • Post Discharge Phone Call within 48 business hours of discharge • Follow up clinic visit within 7 days of discharge • Required Documentation for each call and visit • Only reimbursed if patient is not readmitted for 30 days Labeled for Reuse; http://commons.wikimedia.org/wiki/File:USCapitolDome.jpg

6. Study Purpose • Decrease hospital readmission rates • Address concerns of the newly discharged patient: • Symptom Management • Continuity of Care • Medication Adherence • Reinforce Discharge Education • Outline Plan of Care • Obtain reimbursement picture Labeled for reuse; http://en.wikipedia.org/wiki/File:RedCrossNursen.jpg

7. Action Plan Multidisciplinary Workgroup Providers, Nursing, and Revenue Management Workflow Analysis Discharge Outpatient Billing Implementation Algorithm Development Facilitation of Education Integration of Hematology Services

8. Integration of Services Timeline 2013/2014: July BMT Service September Multiple Myeloma Patients November Hem 4 February Hem 2 & Hem 3 March All services (x Hem 1)

9. Findings July 2013- February 2014

10. BMT Unplanned/Related Readmit Rate Findings Start Post Discharge Phone Calls and Transition Visit Data Source: MIDAS 10

11. Findings Medication Issues Identified Data Source: MIDAS

12. Findings Top 5 Symptoms Identified Labeled for reuse with modifications; http://phonetriage.com/ Flannery, M., McAndrews, L., & Stein, K. (2013). Telephone calls by individuals with cancer. Clinical Journal of Oncology Nursing, 40(5), 464-471.

13. Lessons Learned at Implementation • Communication is key • Inpatient • Outpatient • Accurate interpretation of CMS guidelines • Who can bill for call? • Minimal process changes • Well defined algorithm • Education and follow up critical for process understanding and compliance

14. More Lessons • Data collection and analysis • Intentional data points • Electronic data system interface with EMR • Return on Investment • OSU Fisher of College of Business conducting research

15. Positive Outcomes • Readmission rates were positively affected with consistent calls • Patient satisfaction remains above benchmark • Positive patient and caregiver verbatim It’s the right thing to do for our patients!! Labeled for reuse with modifications; http://themetapicture.com/first-rule-of-buddy-system/

16. Acknowledgements • Transitional Care Workgroup • Joseph Flynn, DO • Jan Sirilla, DNP, RN, OCN, NE-BC • Robin Rosselet, DNP, RN, CNP, AOCN • Weihong Chase, MS, RN, CNP, AOCN • Dareth Gilmore, MSN, RN, CNP, AOCN • Lori Oberholzer, Senior Director Physician Compliance • Jennifer Kelley, Director Compliance and Risk Management • Kristen Johnson, MHA, Senior Data Manager Quality Patient Safety • Amy Dutton, Student Quality Patient Safety

17. Thank You To learn more about Ohio State’s cancer program, please visit cancer.osu.edu or follow us in social media: