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Episode 76: Caring for Patients After Hospital Discharge

by Aledade

Aledade’s Director of Transitions of Care, Dr. Kim Hodge, joins Josh to talk about Transitional Care Management (TCM) visits and the challenge of providing consistent care to patients as they move through different levels of care in a health system.

The two discuss how to conduct an effective TCM visit and what Aledade is doing to encourage and support this work for vulnerable patient populations and how to use telehealth to do this work during the time of COVID-19.

Episode Transcript

Kim Hodge  00:00

I think it's more than the billing. I think it's about wrapping your arms around a patient, whether they think they need it or not, and guiding them through this process of continued recovery.


Hannah Posner  00:12

Welcome to The ACO Show, a podcast about value-based healthcare and the people who make it happen. I'm Hannah Posner, one of the co-producers of the show, along with Brittany Barnes. And for this summer, we welcome Madeline Bender to our podcast team. When we think about healthcare in America, it has been said that we don't have a healthcare system. What we have is many unconnected healthcare businesses. One way this affects patient care is that a hospital might take very good care of you when you are in their facility. But what happens once you get discharged? We know that the time right after hospital discharge is a time of particular vulnerability and risk for patients. But whose job is it to make sure that a patient leaving the hospital actually gets any of the medications that they were recommended or sees to it that a patient can get any scheduled follow-up appointments? The answer for many Americans is that they are on their own to navigate this very complicated process. Our guest this week is Dr. Kim Hodge. Kim has a PhD in nursing with a focus in health systems, and she leads Aledade's efforts to try to improve care and coordination for patients who just had medical or surgical hospitalization.


Josh Israel  01:27

Welcome to the show. I'm Josh Israel, a medical director at Aledade. And I'm delighted today to welcome Dr. Kim Hodge. Kim is an advanced practice RN, and director of transitions of care on our Aledade product team. And, by the way, a very good colleague to meet on our team. Welcome to the show, Kim.


Kim Hodge  01:45

Thank you very much, Josh. I appreciate being here.


Josh Israel  01:48

So we wanted to talk about transitions of care and you were obviously a great person for that. So why don't we start with what is a transition of care and what is a TCM visit and how are they different?


Kim Hodge  02:01

Transitions of care is a very broad term. It is defined as the movement of patients within a facility for example, from the intensive care unit to the step down unit or to the med surg unit, or between settings between the acute care hospital and a skilled nursing facility, or the acute care hospital and the patient's PCP. So you can wrap it up into the movement of patients across the healthcare system and between healthcare providers. And a transitional care visit is a reimbursed visit by Medicare perhaps some other payers as well, where they are providing a fee for care management. So when a patient leaves a facility that's eligible, for example, acute care hospital and they transition to a home setting, for example, their home, when there are certain activities done, CMS allows you to bill for those care management activities and that encompasses a 30-day period of time after the patient is discharged. And that's the billing part of transitional care management.


Josh Israel  03:07

Okay, so it's transition of care is the overall process of how a patient is cared for as they move from an acute setting to another. And the TCM is a specific billable event in that process. Is that right? 


Kim Hodge  03:18

That is correct. 


Josh Israel  03:20

And why has Aledade made TCM visits and transitions of care overall an important part of the work of the company?


Kim Hodge  03:28

Transitions of care, TCM visits in particular, are aimed at patient safety initiatives, keeping patients from readmitted or returned to the acute care setting. When we employ the activities around transitional care management and subsequently bill for it, we are committing to accepting a handover and helping that patient through the next part of their care where they're very vulnerable. So Aledade supports that by surfacing these patients in our app, by prioritizing them, by guiding the number of days to the first interactive contact and when it needs to happen to documenting the outcomes, monitoring what percentage of our high-priority patients got billed, and working to not only facilitate the process of billing for TCM, but the components. We're educating our practices on things that they can do for care management, how to assess for care management opportunities, and really providing the wraparound service of an acute to PCP handover and Aledade supports that throughout the entire process up to and including the billing and post-billing events.


Josh Israel  04:40

And you mentioned the Aledade App. We've spoken about that some on this show, the app being Aledade's data platform that we use to present various parts of population health and information to our practices, and including supporting the billing function. I've heard you say that the billing function is an important part of a TCM visit but not the meaningful part. Can you say more about that?


Kim Hodge  05:02

 The billing is just there to be reimbursed for the activities that are done by a practice to keep patients safe during this vulnerable period of time. So the meaningful part, I believe, is identifying the gaps and closing those gaps so that patients don't have to revert to going back to the acute care system. And I'll give you a couple of examples. A patient is given a discharge plan at day of discharge, and the obligatories say, "Yes, I understand. Yes, I understand. Yes, I understand." They get home, and oftentimes, that piece of paper or papers is never resurrected, it still sits in the discharge packet or sits with the discharge bag. And there are key things in there that we've told or requested the patient do, for example, stop taking these medications, start taking these medications. These are new prescriptions. These are changed prescriptions. You have a home health company that's going to be contacting you, you are going to be discharged home and you're going to need oxygen and this is the company that's going to make sure you get it. When we do the contact with the patient, we can review those to say, "Did you get your new medication?" Oftentimes, if it's an expensive or a new medication, they may not have because they couldn't afford it or they weren't able to get it. "Did the home health company show up, have they contacted you yet? Was your oxygen there when you got it?" So we can identify those things during that contact, that without them the patient is likely to get worse, to readmit, to go back to the ED. The other part is, when you come to the visit, you can review what happened during that and you can review that care plan to say, "Is it still relevant? Are things completed? Is there anything outstanding? What else do we need to do?" And you can do a further assessment with the patient to say, "Do they need home health now?" They may not need a discharge, but are they getting better? Is their antibiotic working? Is what we asked them to do at discharge to help them get better, is it improving?" And then we can put more wraparound service or additional wraparound services for that patient to get them over the next few weeks. So we're really addressing that 30-day vulnerable time by assessing and addressing things that would drive the patient back to the hospital or signs that they're not getting better and they're getting worse or they need different care.


Josh Israel  07:20

So what you're describing there is some of the key components of it, including what a good interactive contact looks like. Can you talk us through what actually are the steps to a TCM visit?


Kim Hodge  07:32

In order to bill a TCM visit, the first thing that needs to happen after the identification of the patient is they need to be contacted within two business days. I want to clarify that, that it's business days after discharge, and that does exclude major federal holidays and weekends. So during that interactive contact is when you are assessing those things that not assessed and addressed prior to the visit may drive the patient back to the acute care setting. The next step in the process that should happen during that interactive contact is to also set up the visit with the patient. For patients that are more complex, there's some clinical judgment that could or should be applied that says, "I really think this patient needs to be seen in the next three days or seven days." And then there are other patients for which you when you've assessed them, and you've identified their needs, their needs may not be as great, their burden may not be as great. And they're oftentimes more appropriate for pushing it out into week two, you know, up to the 14 days, but that does need to happen within 14 days. And day one of that 14-day window is the day of discharge. So sometime between day of discharge and day 14, the patient needs to be seen. I always recommend that earlier is better than later. It gives you time to readjust, regardless of the patient's complexity for transportation issues, anything that might happen, so if you don't push it to the window. The next step in the process is that you actually do this face-to-face visit with the patient, and we know now that face-to-face visit can be done in-person in the office, which is sort of the traditional way to do it. But since COVID-19, we also know that telehealth is a great way to provide that face-to-face visit with patients. So you do the face-to-face visit, you address those things we talked about, you address new things, you talk about the care plan, and together you have a plan of care for the patient to continue their wellness journey. During that face-to-face visit, that is the time that you submit as the Date of Service and the ideal time to submit that bill to CMS or to Medicare to be reimbursed, and then post that visit for the remaining 30 days of the service period and extending further when patient needs indicate, are doing those other things that I talked about, like making sure they're still taking their medication, that they completed their antibiotics, that they're getting along in rehab, that they're able to manage whatever care plan that you came up for them is. Also a good time to consider if this patient is a good candidate for enrollment in chronic care management for continued care beyond 30 days.


Josh Israel  10:03

I would say to anybody listening to this who got a little bit confused by the business days, if you feel like well, I still don't exactly understand which days are which, that's okay. I've been here a little while, I still regularly have to look up what exactly are the TCM requirements. So I wanted Kim to talk us through those people to understand that there are these regulations around it, but the spirit of it is the most important thing. But in order to get reimbursed for it, I recommend you just take a second look at the requirements, and they are something certainly people can meet. I want to also highlight the issue of the reimbursement because we know that a lot of physicians are trying to make the transition to value-based care, while in the meantime, they're having to make payroll based on the fee-for-service system. And that's why a service like TCM is particularly good. It really is about outcomes, it is about doing the right thing, but you can get reimbursed for it. And Kim, how is the reimbursement for TCM compared to other appointments that a physician may have?


Kim Hodge  10:59

The average medic—it's higher, because you're getting paid to provide a month of care management services for the patient. Reimbursement ranges on average for the lower complexity and what I mean is by moderate medical decision making and seen within 14 days in the mid $180 range ish. And that's the 99495 if you're keeping track of codes, and then there's the 99496 code, which is for the patient that's a high medical decision-making complexity, seen within seven days, and that reimbursement is around the 230-ish range to 240-ish range, on average, so not exact, but they are reimbursed higher than a regular E&M visit to accommodate for the care management that's embedded or assumed to be done with those visit codes.


Josh Israel  11:51

Can you say more about the care management piece of it?


Kim Hodge  11:54

So these two codes that I mentioned 99495 and 496. Like Chronic Care Management, like principle care management, they're all in a group of care management codes. And with care management codes, it's not just the physician visit, you oftentimes have ancillary staff or your clinical staff helping as well. Many of those things I mentioned earlier are fundamental to a care management program. So it's taking a plan of care, helping the patient to execute on that setting goals, making sure that gaps are being closed, from medications to transportation, to social determinants of health, to providing education, to coordinating with other services, such as home health or DME companies. But all of those things and more are involved in care management. So when we're getting reimbursed for a TCM, it includes the interactive contact, a face-to-face visit, and these non-face-to-face activities that comprise care management.


Josh Israel  12:53

So when you are working with physicians or anybody in a population health job is trying to work with physicians to help them transition more into value-based care, and you're speaking about Transitional Care Management visits, transitions of care, what do you show providers to persuade them of the importance of this? Where have you found successes?


Kim Hodge  13:14

For me, I use the patient and the benefit to the patient of providing transitional care management or care management in general, regardless of whether the goal is to be reimbursed for it. Of course, I believe that you should be reimbursed for your work, but patients are vulnerable. This 30 days after discharge is a time where patients sometimes know what to do, sometimes don't, sometimes have caregiver support, sometimes don't. I worked in the acute care environment for 30 years, we throw a lot out them because we're trying to manage length of stay in the hospital. They say yes, they understand everything. But in reality, they need someone to hold their hand. I liken it to a handover, and it's managing that handover for the patient so that they're safe, they can execute on what we want them or they want to do to be safe. They resolve whatever it is, or at least stabilize whatever it is that took them to the acute care setting, and that they have a successful transition back to whatever their normal is. So I think it's more than the billing, I think it's about wrapping your arms around a patient, whether they think they need it or not, and guiding them through this process of continued recovery. We discharge patients from the hospital, and sometimes we forget to tell them, "Hey, you're still sick." But when you go home, you're still sick oftentimes, if you're recovering from something. Very few patients go home and they're, they're fixed. So to me, it's more about "This is in the best interest of the patient," because whether they acknowledge it or not, they really need us to take that handover and to manage it so that they can achieve their health goals and they can stay safe in their home and they cannot have to go back to the acute care setting.


Josh Israel  15:03

Is there anything else you think that Aledade's app, our data platform, shows to practices that help them with this?


Kim Hodge  15:11

As we discussed already, TCM has a lot of process steps. The app helps us to know how well we're performing in the process steps in order to be able to bill. I think the app is great for surfacing our eligible patients, prioritizing those eligible patients for us, letting us document the outcome of outreaching to them. We are able to share with practices not only your outreach, but also how many of those patients that we surface for you actually got a visit scheduled. You know, that's a significant process where you could do process and practice improvement between your scheduler and whoever's calling the patient. It could be a clinical staff or the billing provider. It just helps you solidify and get really good at this process. Reports we can run from those activities in app can give you information about how many visits did you actually bill as TCM? What was the distribution of those between less complex and more complex? How did you do on meeting the 14 days or the seven days? What were the readmission rates for those patients. So we're giving you this feedback. When you work in the app itself, it helps you organize your day and prioritize your patients and know who to call and know what the timeframes are. And then based on that work, and then the claims that we can combine with that, we're able to give you feedback on how you're achieving outcomes for the patients that are in your practice.


Josh Israel  16:37

I just heard you give a great talk for about 200 physicians and other health care providers, a webinar on this topic. What else is is Aledade doing as part of a broader curriculum and educational efforts around this?


Kim Hodge  16:50

For transitions of care in general, we're really trying to make sure that practices have the tools they need, the information they need to know who to outreach to, why it's important. Some of the things that we've already talked about during this chat about what it means to patients, but also what it means to the practice, what it means to them as they're trying to make sure that they're taking care of the most vulnerable patients, how to pivot, and we're helping them transition to telehealth and use telehealth as a platform to do TCM, particularly for patients that you'd prefer that they stayed at home because they're safer there. Those are probably some of the big things, is just recognizing the importance to patients. This is a key thing. Other things we're doing is drawing the relationship or creating the continuum from ED prevention as a transitions of care, to the TCM visit, to "Is this patient good to continue into a care management program for chronic care management or principal care management?" But I think overall we're really just trying to surface those patients that would benefit from not just care but timely care, because there's time sensitivity in there when patients are in their most vulnerable period and surfacing those and then helping practices to work through how to provide care for those patients and to get the feedback that they need about how well they're performing.


Josh Israel  18:16

Is there anything else that you think we should be thinking about right now in this time of COVID-19?


Kim Hodge  18:22

That's a great question, Josh. I think we need to think about our most vulnerable patients, how we're providing wraparound care, how we're accepting these handovers when patients go to acute care settings now. I believe if we've read the literature, and most of us have, we know that they're not going as often as they did, they're delaying care. So when the patients are getting to the hospital, they might be sicker than they may have been back in December or November. And recognizing that they need us to pick up and take over where the hospital left off so that we can help them to continue to get better. We're going to have to integrate, "Did the patient have a COVID-19 exposure? Do they have COVID-19? How does that fit into my plan of care now?" We're going to have to consider, are they more debilitated because they're discharging, they're discharging to home, but they spent 10 days in an ICU, which means that they were likely really sick, and they probably didn't get the activity they needed, and they might be debilitated. So we have to think that the patient may have gone or been before they went to the hospital less complex, but now because of why they were the hospital, they're more complex, they're more sick and they're more frail. It's a good time to really make sure that we understand their advanced care planning, beliefs and preferences and choices so that we've had those conversations before but definitely afterwards. Just challenges us to think about providing care to patients who are likely more ill and less likely to return to the hospital until it's maybe too late.


Josh Israel  20:02

Well, this is great, Kim, I really appreciate the way that you are thinking about the use of a specific billing code to really get the right thing done for vulnerable patients.


Kim Hodge  20:13

Thank you very much. I appreciate you having this conversation with me.