Care Management‐Transition of Care (TOC) Notice Additional In‐Services Added

The MPP Care Coordination Team will begin providing a nurse‐led TOC encounter for high‐risk patients* discharged from a qualifying facility. The interaction will occur within two business days of discharge and include:

  1. New and existing medication education, questions and compliances
  2. Disease specific education and self‐management
  3. Review of discharge instructions to include social need and support programs that promote adherence to plan of care
  4. Follow‐up appointment scheduled (within 7 days)
  5. Contact with PCP office as needed

A summary of this interaction will be sent to the office via your preferred mode of communication where it will need to be reviewed by the physician and added to the medical record.

This program targets reducing readmissions and avoidable ED visits, increasing compliance with PCP plan of care, follow‐up appointment, and improving the overall care experience. To ensure the success of this program the physician and office staff need to a) understand the importance of the follow up visit within 7 days, b) educate office staff on the program, and c) view the Care Coordination team as part of your team.

If you could not attend the previously scheduled webinars, please see attached with additional dates. Please join us for an informational webinar that will provide specific detail, example reports, and billing education.

For more information please contact Andrea Phillips, RN, BSN, MA @ 248‐484‐4947 or