Transition of Care (TOC) Log Instructions (Effective: 4/15/14)

Transcription

1 Transition of Care (TOC) Log Instructions (Effective: 4/15/14) General Instructions: Please note that each transition requires a separate form. For example, an admission to the hospital should have one completed transition of care (TOC) Log. The return to home setting should have a separate TOC Log. Every TOC requires a TOC Log, even if you learn about it after the transition has occurred. As noted below, communication tasks are to be completed within 1 business day of notification. Document date of completion or attempt. If attempted and not completed, address in comment section. Item Header Instructions 1. Member Name Enter member s full name. (Last, first middle) 2. MCO Name Enter the member s health plan name. 3. PMI# Enter the DHS assigned Person Master Index (PMI) Number used in MMIS, also known as Member ID or Client ID. 4. Product Enter the type of plan. (e.g. MSHO, MSC+, SNBC) 5. MCO/Health Plan Enter the member number used within the health plan. Member ID# 6. Care Management Enter the care coordinator/transition manager name. Contact 7. Agency/County/Care Enter the care coordinator s agency, county, or care system. System Transition Log Information 8. Notification Date Enter the date you or your agency was first notified of the transition. 9. Transition Date Enter the date the member moved from one care setting to another. If date not known, document unknown for this item. 10. Transition From Enter the type of care setting the member transitioned from: e.g. home, assisted living, hospital, skilled nursing facility (SNF), transitional care unit (TCU)/rehabilitation facility, mental health or chemical dependency residential treatment. Check the appropriate box to indicate whether this is the member s usual care setting? 11. Transition To Enter the type of care setting the member transitioned to: e.g. home, assisted living, hospital, SNF, TCU/rehabilitation facility, mental health or chemical dependency residential treatment. Check the appropriate box to indicate whether this is the member s usual care setting? 12. Transition Type Check the appropriate box to indicate whether the transition was planned or unplanned. Planned transitions include elective surgery, planned move to a SNF, etc. Unplanned transitions include an unscheduled hospitalization, an unscheduled move to a SNF, etc. TOC Log Instructions 2014 Update Effective doc Page 1

2 Transition Description Include a brief note explaining why transition occurred: e.g. hospital admission due to [reason]; change in current health status; or discharge due to stabilization. Communication Tasks (To be completed within 1 business day of notification of transition) 13. Notified primary care provider (PCP). 14. Shared care plan with receiving setting. 15. Communicated with party about changes to the member s health status and plan of care. 16. Communicated with party about the care transition process. 17. Educated party about transitions and how to prevent future unplanned Enter the date the member s PCP was notified and check the box as to the method of notification: e.g. fax, phone call, or communication via electronic medical record (EMR). If the member s PCP was the admitting physician, check the appropriate box and enter not applicable (N/A) for date completed. PCP notification, within one business day, is required regardless of the date care coordinator is notified of TOC. Receiving setting includes: e.g. home, assisted living, hospital, SNF, TCU/rehabilitation facility, mental health or chemical dependency residential treatment. Enter the date care plan was shared with the receiving setting. The care plan may include the Collaborative Care Plan (CCP) or the hospital/snf discharge instructions, etc. Relevant information (current services, informal supports, advance directives, medication regimen, contact information, etc.) may be communicated via phone, fax, secure or in person. Enter the date changes to the member s health status and care plan were communicated to the party. Communication should include an update of known medication changes, durable medical equipment (DME) products required, services needed, etc., resulting from a change in the member s health status. Enter the date the care transition process was communicated to the party. During the transition, it is expected that the care coordinator explains the transition process and provides contact information for additional support. The transition process includes identifying at-risk members, communicating and helping the member to plan and prepare for transitions, and follow-up care after the transition. Communication may also occur with the discharge planner; however, this does not take the place of communicating with the party. Enter the date the care coordinator discussed with party possible steps to prevent future unplanned care transitions: e.g. readmission to a nursing home, rehospitalization. Discussion can include but is not limited to talking about reducing fall risk, improving medication management, improving nutritional intake, additional services, advance care planning, etc. TOC Log Instructions 2014 Update Effective doc Page 2

3 transitions/ readmissions. Four Pillars for Optimal Transition (For discharge to usual care setting) This section should be completed only when the member discharges TO their usual care setting. Check Yes - if the member, family member and/or SNF/facility staff manages the following: 18. Follow-Up Appointment 19. Medication Self- Management 20. Knowledge of Warning Signs 21. Personal Health Care Record Indicate whether member has a scheduled follow-up appointment, ideally within 15 days of discharge. Suggested questions include: When is your follow-up appointment? How are you getting to your appointment? Assist with making the appointment if necessary. Stress the importance of keeping appointment and address potential barriers. Determine whether party have an understanding of current medication regimen. Suggested questions include: Do you have all of your current medications? What changes were made to your medications? How do you get your medication from the pharmacy? How do you remember to take them? Do you need help with setting up or taking your medications? What questions do you have about your medications? Assess need for referral to home health services or Medication Therapy Management Services (MTMS) if eligible. Indicate whether the party are aware of symptoms that indicate problems with healing or recovery. Suggested questions include: What are the warning signs that might indicate you are having a problem with healing or recovery? What should you do if these symptoms appear? Who do you call if you have questions or concerns? Do you have those phone numbers readily available? (Consider this a possible lead-in to the discussion about personal health care records). Indicate whether party use a personal health care record for tracking health history and current regimens. Check Yes if visit summary, discharge summary, and/or healthcare summary are being used as a PHR. Suggested talking points include: Point out the advantages of having an organized account of personal health information. Explain that this is a good place to record their medical history, allergies, medications, visits, test results, immunizations and hospitalizations. Encourage member to bring this record to their provider appointments and to write down questions for TOC Log Instructions 2014 Update Effective doc Page 3

4 Transitional Care Follow-Up 22. Care Plan Update their health care team. Indicate whether the member s care plan has been updated following this transition. Check N/A if SNF/facility staff, is responsible for the care plan. If no, explain. Be sensitive to the member s concerns and goals. Incorporate them into the care plan when possible. Address newly identified medical issues. Example: increased fall risk. TOC Log Instructions 2014 Update Effective doc Page 4

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