Improving Care for Patients Transitioning from Hospital Acute Care to Home

Rosha L. Hamilton, DNP, MSW, BSN; Judith A. Walloch, EdD, RN; Karen Lauer, BSN, RN, MSOLQ; Thomas W. Zoch, MD, FACEP, FACP, CPE


Nurs Econ. 2021;39(2):59-66. 

In This Article


Project Design

The project design was a QI approach to the current care model. Implementation of standard work protocols included adding patient TCM outreach phone calls within 48 hours and post-discharge appointment with their PCP within 7–14 days. Further, the medication reconciliation process was reviewed and documentation improved. These changes allowed for utilization of CMS TCM billing codes.


The TCM project took place in an integrated health system involving a hospital in a region of the statewide system. The registered nurse care manager (RN-CM) was most directly affected by this project. The RN-CM worked for the organization for over 5 years and was invested in this pilot program's success. The RN-CM made the outreach calls to the patients after discharge. Also included in the project were 133 PCPs who needed to submit the correct billing code.

Patients impacted by this project were discharged to home after an observation or inpatient hospital stays in one of the two acute care hospitals. Inclusion criteria included patients who were Medicare beneficiaries and had a PCP within the health system. In 2018, the project hospital discharged 9,527 Medicare beneficiaries to home for a monthly average of 793. In 2019, the monthly average for the first 3 months was 512 Medicare discharges to home.


The first step in implementing the program was training the RN-CM on the use of the care management platform. The care management platform allows the RN-CM to identify discharged patients. The care management platform not only sent admission-discharge-transfer alerts, but it could also report on the care manager activity tracking the call completion.

The next step was updating the RN-CM outreach protocols and documentation of post-discharge phone calls in the electronic medical record (EMR). A standardized TCM documentation template was created for care manager use. This template ensures the notes include appropriate comprehensive patient information for the PCP's use at the follow-up visit, including psychosocial, physical, and emotional aspects of the patient's status. Training on the TCM documentation template also included how to determine if the patient had a scheduled appointment and, if not, schedule the appointment. The next step was educating the PCPs on the TCM billing components and process. This was done via train-the-trainer through an educational presentation. The clinic managers were trained on the process, and they trained the providers at their clinics. If these providers do not submit the correct TCM billing claim, no change will occur.


To evaluate the impact of the 3-month pilot, the analyst collected data monthly on the fiscal impact and the 30-day readmission rate. Data were analyzed for trends and month-to-month performance.