Transitions of Care | April 2022 | Clinical Corner

April 15, 2022

Transitions of Care – Best Practice

Increasingly, health care is focusing on primary care outside of a hospital setting. Patients are vulnerable when they transition between different parts of a health care system, these care transitions threaten patient safety.

Transitions of Care (TOC) are changes in the level, location, or provider of care as patients move within the health care system.(1) The consequences of poor transitions of care are multiple: (2)

  • Patient care delays
  • Staff stress and frustrations
  • Increased practice workload
  • Increased risk of urgent care and emergency room visits
  • Readmission
  • Patient & family dissatisfaction
  • Negative image of the medical facility and the physician practice
  • Poor patient outcomes

The most recent MPP transition of care rate for a 14-day follow visit after discharge from a hospital as of November 2021 was 66.5% (target of 70%).

The factors that influence a successful transition of care are (1):

  • Discharge communication
  • Pursuing a follow-up appointment
  • Medication reconciliation
  • Knowledge of and addressing outstanding tests and services
  • Access to care coordination

    We wish to thank the practice units listed below in the references for providing best practices they use for attaining and maintaining a high percentage of TOC visits. (3)

  • On the first post-discharge call, McLaren Physician Partners TOC nurses are making TOC appointments with the primary care physician or next provider.
  • The physician and providers in the office are committed to the transition of care process and prioritize those patients and appointments.
  • Once the practice identifies an eligible TOC patient (through fax, phone, EHR, mail, email), they follow the patient until discharge, then contact the patient for follow-up appointment.
  • When a patient has been discharged from a facility, the practice contacts the patient for a follow-up appointment. (if not already done by MPP Transition Care Management team).
  • The practice determines the discharge date from the patient, hospital or nursing facility and awaits the discharge date to make an appointment for follow-up.
  • The practice has a close relationship with the hospital TOC team and waits for the notification of discharge to communicate with the patient regarding the follow-up appointment.
  • The Practice creates and holds TOC slots on the physician/provider schedules.
  • The physician/provider would initiate a referral to the MPP Care Coordinator for care management services at the TOC visit.


    The CPT codes for the TOC services are 99495 and 99496. Reimbursement is up to $199.43 for the 99495 and up to $268.86 for 99496.

    As there is no one size fits all approach for the TOC process, a customized, evidence-based approach will yield the following according to the literature (4):

  • Patient and support person(s) satisfaction
  • Increased patient confidence in self-care
  • Marked reduction in readmission
  • Medicare cost savings

The trauma of hospitalization is intense to a patient – let’s make the discharge and transition effective, efficient, and less stressful for the patient and the medical practice.


  1. Annals of Internal Medicine, In the Clinic, Transitions of Care, 3/5/2013.
  2. Barbara King PhD RN, The Consequences of Poor Communication during Hospital to Skilled Nursing Facility Transitions: A Qualitative Study, J Am Geriatric Soc, 2013 Jul.
  3. The practice sites of:
    1. McLaren Oakland Dixie Highway Internal Medicine
    2. Michigan Internal Medicine & Associates
    3. McLaren Macomb Internal Medicine
    4. Partners in Family Medicine
    5. The Practice of Dr. Brenda Rogers-Grays
    6. McLaren Flint Flushing Community Medical Center
    7. McLaren Greater Lansing Okemos Primary care
  4. Melanie Logue, Evaluation of a Modified Community Based Care Transitions Model to Reduce Costs and Improve Outcomes, BMC Geriatrics, 2013 Sept 12.