Standardization of Transition Care Management (TCM) Workflow in a Safety Net Hospital Increases Percentage of Completed TCM, Increases Revenue and Decreases Hospital Readmission

Judella Haddad-Lacle^1, , Brittney Costello¹, Charles J Haddad¹, Jessica-O'Vaughn Lance¹, Alexanderia Burwell¹, Amy McCoy¹ and Kelly Gray-Eurom¹

¹University of Florida, Jacksonville, USA

Cite this paper

Judella Haddad-Lacle, Brittney Costello, Charles J Haddad, Jessica-O'Vaughn Lance, Alexanderia Burwell, Amy McCoy and Kelly Gray-Eurom. Standardization of Transition Care Management (TCM) Workflow in a Safety Net Hospital Increases Percentage of Completed TCM, Increases Revenue and Decreases Hospital Readmission. American Journal of Public Health Research. 2022; 10(1):32-35. doi: 10.12691/AJPHR-10-1-6

Abstract

The Centers for Medicare and Medicaid Services (CMS) in 2013 began offering payment to ambulatory practices for the transitional care management (TCM) service to address readmission rates. The adoption of a successful TCM model is needed to improve patient outcomes and lower readmission rates. At UF Health Jacksonville, we formed a dedicated TCM team whose role was exclusive to the completion of the TCM non-face-to-face process (NF2F). The team elected to utilize the Define, Measure, Analyze, Improve, and Control (DMAIC) model as the process improvement methodology to guide the project. UF Health Jacksonville has eliminated many of the barriers facing Academic Center Safety-net Hospitals as it relates to readmissions by implementing this approach. After the implementation of the dashboard and all of the improvements, there was an immediate return on investment increase of 81.06 percent exceeding the projected goal of 75 percent and decrease in readmission rate to as low as 5 percent.

Keywords

Transition Care Management, hospital readmission, revenue

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Gilman, M., Adams, E., Hockenberry, J., Milstein, A., Wilson, I., & Becker, E. (2015). Safety-Net Hospitals More Likely Than Other Hospitals To Fare Poorly Under Medicare’s Value-Based Purchasing. Health Affairs, 34(3), 398-405.
[2]	Bloink J, Adler KG. Transitional care management services: new codes, new requirements. Fam Pract Manag. 2013; 20(3): 12-17.
[3]	Patel NK, Mathew R, Aniemeke C, Tripathy C, Jaen CR, Tysinger J. Transitional Care Management: Practical Processes for Your Practice. Fam Pract Manag. 2019 May/Jun; 26(3): 27-30. PMID: 31083872.
[4]	Ohuabunwa, U., Johnson, E., Turner, J., Jordan, Q., Popoola, V., & Flacker, J. (2021). An integrated model of care utilizing community health workers to promote safe transitions of care. Journal Of The American Geriatrics Society, 69(9), 2638-2647.
[5]	Otsuka, S., Smith, J., Pontiggia, L., Patel, R., Day, S., & Grande, D. (2018). Impact of an interprofessional transition of care service on 30-day hospital reutilizations. Journal Of Interprofessional Care, 33(1), 32-37.
[6]	Nall, Ryan. “An Interprofessional Primary Care-Based Transition of Care Clinic to Reduce Hospital Readmission.” The American Journal of Medicine. (2020) 133: e260-e268.
[7]	Bindman, Andrew. “Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries.” JAMA Intern Med. 2018; 178(9): 1165-1171.