Transitional Care Management

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1 Transitional Care Management HE ALTH SOLUTIONS consulting technology innovation A DIVISION OF AVASTONE TECHNOLOGIES, LLC I avastonetech.com/healthsolutions

2 transitional care management I Avastone Health Solutions Microsoft xrm Assists with Managing Transitions in Care There s no debate that health care today is often disparate, fragmented and administratively complex to manage. Microsoft xrm provides an integrated platform that propels patient management into a collaborative, holistic and integrated care model. The Microsoft xrm solution will bridge efforts within and across organizations: whether you are striving to achieve Patient Centered Medical Home (PCMH) accreditation; taking risk through an Accountable Care Organization (ACO); looking for ways to enhance patient engagement; or simply moving to a system based care model. The results will be visible through increased ability for comprehensive care management, efficient care coordination and pronounced patient engagement. xrm allows for flexibility, accountability and transparency that health care organizations simply aren t achieving with electronic health records today. 2

3 transitional care management I Avastone Health Solutions COST CONTAINMENT In October 2012, the Centers for Medicare and Medicaid Services (CMS) implemented a maximum 1% financial penalty to hospitals with too many hospital readmissions, specifically targeting the non-surgical conditions of acute myocardial infarction (AMI), heart failure and pneumonia with more planned. The Hospital Readmission Reduction Program (HRRP) is a direct result of nearly 1 in 5 Medicare patients returning to the hospital each month with a price tag of over $17 billion annually. In addition to readmission, patients within the critical 30 day window following facility discharge face other adverse events including non-adherence and medication errors. Whether you are a hospital, the physician or patient, or other provider of service, everyone benefits when working together to transition patients into the community safely. Reimbursable Service Added in ushers in a new era by which Medicare and commercial payers have stepped up willing to tie reimbursement to team-based transitional care management services, reinforcing the concept of managing specific patient populations and the continued evolution to system based care. Seeing a need to reduce unnecessary hospital readmissions, the CMS and commercial payers have initiated payment through the use of of new CPT codes and for the successful transition of patients from a facility setting into the community. Transitional Care Management, a fee-based 30-day service, is reimbursable to a physician and his/her care team following the successful management of a patient transition. The CMS estimates that 70% of all nonsurgical facility discharges are eligible for Transitional Care Management services and thus, reimbursement. Payment for CY2013 is approxmately $160 to $230 per billed service depending on the medical complexity of managing each patient. A physician group with 200 qualifying discharges per month could realize up to $552,000 per year of added reimbursement. A potential failure in the care coordination of patients during post-discharge transition today is the lack of a real-time safety net to catch a patient and successfully migrate them back into the community while mitigating their immediate needs. Delayed or incomplete documentation and communication between hospitalists and other hospital physicians with primary care physicians is identified as a key area for improved management. Often times discharge summaries are not completed, reviewed timely, or the patient is solely responsible for scheduling follow-up visits with the primary care provider. Transitional Care Management services aim to fill these gaps by requiring interactive communication between the patient or their caretaker and the primary care physician team within 2 business days. Medication management and reconciliation, and discharge summary review are primary requirements in the delivery of Transitional Care Management. These activities must be completed prior to the face-to-face visit, which occurs between 7 and 14 days of discharge, and is governed by the complexity of the patient. Examples of Transitional Care Management services provided by the physician and the health care team include: Self-management and ADL education Coordination of referrals Diagnostic test results review and management Medication management Facilitating access to care and support services Better transitions of care effectively turns effort into outcome and when coupled with an integrated technology solution, team based patient management can be achieved in a cost-effective, scalable method. 3

4 TRANSITIONAl CARE MANAGEMENT I AVASTONE HEALTH SOLUTIONS The xrm solution provides a patient-centered approach to managing care while allowing flexibility and transparency to the entire care team. 4

5 TRANSITIONAl CARE MANAGEMENT I AVASTONE HEALTH SOLUTIONS Sample Transitional Care Workflow 5

6 transitional care management I Avastone Health Solutions Current Solutions The majority of existing patient management solutions available to hospitals and health care systems today typically rely on predictive analytics and managing at risk patients using multi-step resource intensive manual processes. Neither have proven to be effective. Designed to complement existing hospital and clinic electronic health record (EHR) systems, Microsoft xrm is a low-cost, intuitive, software solution that enables the care team across the continuum of the patient to track and coordinate data. Examples of use include: Communication of post-discharge care information and reminders to patients and caregivers Application of custom protocols (workflows) including: reminders for office visits and prescriptions, education and information, and care coordination Ability of care team to identify patients and caregivers that aren t accessing the information Automation of workflows reducing duplication and increasing accuracy Generation of reports and dashboards that identify cases missing information or ready for billing TECHNOLOGY Microsoft xrm provides a scalable, secure, robust, and customizable platform to manage the TCM process along with the foundation to deliver many other solutions for healthcare. Ease of use is essential and Microsoft s commitment to a strong user experience is evident in the navigation and usability of xrm. The xrm framework is a true N-Tier application providing a standard service layer for access to the information while ensuring a high level of security. This service-enabled platform provides an environment for mobile applications and devices to tap into the information and deliver it in many ways and on many devices. You can update your case information through the most convenient device including ipad, iphone, Android, Windows Mobile and others. Summary Pursuing xrm for managing transitions of care shouldn t be considered simply for the reimbursement on the table, but rather as a mechanism to seamlessly manage patient populations with a transparent, team-based approach that ultimately strengthens the patient/physician relationship. Ability to provide audit trails as required for compliance Easy and flexible access by multiple users in different locations across the system 6

7 TRANSITIONAl CARE MANAGEMENT I AVASTONE HEALTH SOLUTIONS For More Information or to Schedule a Demo Greg Borchard Director Business Development Avastone Technologies Ext 1222 Penny Osmon Bahr Director of Avastone Health Solutions HE ALTH SOLUTIONS consulting technology innovation A DIVISION OF AVASTONE TECHNOLOGIES, LLC I avastonetech.com/healthsolutions 7

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