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Glossary

Transition of care

The movement of a patient between settings or providers, most often from a hospital to home or a facility. The records have to move with the patient: the hospital must send the necessary information at discharge, and Medicare's transitional care management codes require a review of the discharge information.

Also care transition, transitional care, TCM

A transition of care is the moment the history is most needed and least available. The patient leaves one organization’s record and enters another’s, and what crosses with them is whatever the discharging side chose to send. Two sets of rules try to close that gap from either end.

On the sending side, 42 CFR 482.43 requires a hospital to send “necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences” to the post-acute provider at the time of discharge. What that produces is the discharge summary and the referral paperwork, when the summary is finished in time.

On the receiving side, Medicare’s transitional care management codes (99495 and 99496) pay a practice for managing the thirty days after a discharge, on three conditions: an interactive contact with the patient within two business days, a face-to-face visit within seven or fourteen days depending on complexity, and non-face-to-face work that explicitly includes obtaining and reviewing the discharge information, reviewing the need for follow-up on pending tests, and reconciling medications. The code assumes the practice can get the discharge information; it does not say how.

That is the gap. The receiving organization is responsible for knowing what happened at the hospital, and the hospital’s obligation ends with what it sent. A network query is the mechanism that lets the receiving side go and get the rest: the summary once it is signed, the consult notes, the results that were pending at discharge, from the hospital’s own system, without waiting for a second fax. For care coordination teams managing transitions at volume, that is the difference between a program that reconciles medications against the hospital’s list and one that reconciles against the patient’s memory.

Where it is defined

Vivlio for care coordinationThe intake checklist, from progress notes to medications, assembled before the care plan meeting.

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