Transitions of Care (TOC)

One of the key strategies to succeed in the value-based care environment is the appropriate management of the post-acute period. Commonly, many patients receive care without their care team being aware of the services they received. All too often, PCPs complain they were not aware their patient was in the hospital and also that they have difficulty retrieving the patient’s records from non-McLaren hospital systems.

Transitions, or “handoffs,” are vulnerable exchange points that contribute to unnecessarily high rates of health services use and health care spending, and they expose chronically ill people to lapses in quality and safety.1  A systematic review of interventions to improve the handover of patient care from hospital-based teams to primary care physicians found that multicomponent interventions that include medication reconciliation, use of electronic tools to facilitate communication, and shared involvement in coordinating follow-up care reduce re-hospitalizations and improve patient satisfaction.2

McLaren Physician Partners (MPP) and the McLaren High Performance Network LLC (MHPN) have created a post-acute care program in an effort to improve the coordination of care that our patients’ receive. This program consists of notifying the PCP office when their patient receives an episode of care. These episodes include ED visits, hospital admissions and discharges, and transfers to post-acute care facilities such as skilled nursing facilities (SNFs).  These notifications occur the same day, and in near real time, utilizing admission, discharge and transfer (ADT) “pings” from Patient Ping for patients in our shared savings contracts including Medicare Advantage plans. For our MSSP ACO (Medicare Shared Savings Program Accountable Care Organization) traditional Medicare fee-for-service patients we will be utilizing Athenahealth care coordination software.

Our Post-Acute Care strategy focuses on identifying the patient as they receive a service in a health care system and on providing coordinated care of the patient during this transitional period. We have set a standard of care in which the expectation is that a patient receives a TOC visit within 7 days of discharge from either the hospital or a SNF. Contact with the patient during this period is critical to reducing potentially unnecessary care episodes which include repeated ED visits or readmissions to the hospital.

During this TOC visit, at a minimum, the patient should receive education on the condition causing the admission, chronic condition management, follow-up of pending test results or ordering recommended follow-up testing, and medication reconciliation of their discharge medication list with their home medication list. Documentation of this component requires notation that the two lists are reviewed and updated as necessary. Billing the CPT II code 1111F will signify this reconciliation is done and will satisfy the Medicare Stars HEDIS measure. Additional transitional care management codes (CPT 495 and CPT 496) may be billed if specific CMS requirements are met.  For more information click here.

Practice transformations may be necessary to meet the expectations of the 7 day TOC visit. These may include open access scheduling with same day slots reserved for acute appointments, extended or non-traditional hours (outside of 8am-5pm), or keeping 2-3 dedicated TOC slots open each week.

MPP has created a care coordination scorecard which tracks the percentage of TOC visits occurring within 7, 14, or 30 days. The MPP and MHPN Boards have set the goal of 75% of TOC visits occurring within 7 days.

Our current performance is 41%.

MPP also tracks the number of discharges per quarter to enable a practice to estimate the number of TOC visits they can expect will be needed.

  1. Mary D. Naylor, Linda H. Aiken, Ellen T. Kurtzman, Danielle M. Olds and Karen B. Hirschman The Importance of Transitional Care in Achieving Health Reform.
    Health Affairs
    no.4 (2011):746-754
  2. Hesselink G, Schoonhoven L, Barach P, et al. Improving patient hand-overs from hospital to primary care: a systematic review.
    Ann Intern Med.
    2012; 157(6):417-428

If you have questions, please contact Dr. Michael Ziccardi, Medical Director at (248) 484-4923 or