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  • 1.  TCM Calls

    Posted 05-28-2024 14:29

    Hi all, 

    I am a manager of an ambulatory CM team. The team's primary role is completing the CMS Transition of Care Management (TCM) calls post discharge. This was the process when I stepped into this role and trying to better understand how other organizations complete this work. 

    Is this completed by the clinic team RN for that specific provider or do many organizations have an RN CM team that completes these? Would love to hear more about how your organizations complete this? 

    Thank you in advance, 

    Danielle Peterson MSN, ACM-RN

    She/Her/Hers

    Manager, Ambulatory and Emergency Department Care Management 

    1415 East State Street #608

    Rockford, IL 61104-2227

    Office: 779.696.8060

    Cell: 815.985.8373



    ------------------------------
    Danielle Peterson MSN ACM-RN
    Manager, Ambulatory Case Management
    UW Health- NIL
    Rockford IL
    (815)985-8373
    ------------------------------


  • 2.  RE: TCM Calls

    Posted 05-29-2024 08:25

    Good Morning,

     

    We have a CM team that completes the call and then schedules the patient if they are not scheduled.

     

    Thank you,

    Linda

     

    Linda Postula, MHA, BSN, RN

    Chief Nursing Executive, Faculty Practice Plan

    Office: 314-362-1092

    Cell: 618-304-8495

    Physicians_DIGITAL_pos(CMYK)

     

     

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    Original Message


  • 3.  RE: TCM Calls

    Posted 05-30-2024 07:56

    At UCM, we have a dedicated Population Health Nurse Navigator team that completes TCM calls for our entire system, including OON, and a Care Coordination team that focuses on the 10% most at risk within our ACO. We have escalation pathways for different practices and a separate one for our OON discharges. The team does what they can to remedy the patient's issues and will escalate more complex needs as needed. We make 3 attempts to reach the patients across 2 days, leave messages if needed, and send a MyChart message after 3 attempts if they have an open account. We have a set Epic template to ensure consistency in calls and capture all of the questions, we also added an "attestation" within a telephone encounter that we document if we are unable to reach the patient, which helps us track. Even for those patients that we don't reach, if they have a UCM PCP we ensure that they have an appointment within 7-14 days. We track any issues identified during the call, i.e. didn't pick up meds, no wound care instructions, DME not delivered, etc.

     

    In addition to doing TCM calls, we've set up a dedicated Post-Discharge line that gets answered by our Pop Health team. This is provided to all patients at the time of discharge and they can call with questions or needs when they aren't sure who to call or if they don't have an established in-network PCP that can answer questions. This has been an invaluable addition to our 30-day readmission work. We track the calls so that we can trend the questions and issues patient report, similar to TCM calls.

     

    We recently implemented TCM calls and our discharge line at our community hospital and within the first 2 months saw a around a 25% decrease in readmissions. I think the most essential part of this work is actually speaking with the patient and assessing how they are managing at home, ensuring all meds, DME, etc. have been received, that home health has contacted them if ordered, etc. and then helping the patient to get those things they need or answer questions – these are the things that we have seen bring patients back to the ED and often readmitted.

     

    Sarah L. Kundrat MSN, RN, NEA-BC

    Executive Director, Ambulatory Nursing

    Associate Chief Nursing Officer

    UChicago Medicine

     

     

     

     




    Original Message


  • 4.  RE: TCM Calls

    Posted 05-30-2024 08:55

    Wow this is amazing! Would you be open to sharing more? I love the work you're doing, and I am consistently looking for evidence-based information on care management programs, but most information is how to get started. No real process, FTEs, or productivity metrics. 

    1. # of FTEs for each team
    2. Are they RNs, MAs, etc.
    3. How many calls do they each complete in a day on average?
    4. Is there a way to share how you have some of this set up in Epic? We have templates but capturing some of this data has been challenging. 


    ------------------------------
    Ashley Rosa
    Mgr, Ambulatory Care Mgmt
    Bronson Healthcare Group
    Battle Creek MI
    12693170511
    ------------------------------

    Original Message


  • 5.  RE: TCM Calls

    Posted 05-30-2024 10:29

    I love that we are bringing up this topic and there are others to collaborate with!

     

    My team supports 33 primary care offices and 4 hospitals (2 are small). In most we have a nurse care manager and social worker (some do have more than one office but all offices have support) embedded. We have a centralized team of MSWs, RNs, MAs, and support staff. Our structure is: 4 RNs and 4 MAs making calls to hospital and ED discharges, 1 RN calling peds, and our MSWs call discharges with behavioral health needs but also deploy to offices to assist with assessments. We prioritize based on high risk diagnosis then risk score, and we omit patients based on criteria we developed (surgical, OB, TEE, and some others). Our hospital TOC calls are only for our primary care attributed patients. We are in the 90th percentile of completing our TOC calls. We also have 2 part time RNs who share the load of calling our attributed patients who are discharged from an external hospital system.

     

    One area we have challenges in is capturing SNF patients when they discharge back home and behavioral health patients discharging from an inpatient facility. Another challenge we have is demonstrating impact on readmissions (capturing actual data). If anyone has a dashboard in Epic I would love to hear more about this!

     

    I am interesting in learning more from others and improving ambulatory care.

     

     

    Ashley Rosa, MSN, RN

    Manager Ambulatory Care Management

    Bronson Healthcare Group

     



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  • 6.  RE: TCM Calls

    Posted 05-29-2024 12:03

    Hello -

    Would like to connect possibly as we struggle to break through 60% completion of the phone calls and therefore the TCM completion continues to be our opportunity. Currently, Care Management reaches out to the Medium and High risk for readmission. The low risk are the responsibility of the clinic RN. We are going to be introducing a new digital loop to assist with this outreach which will automate the outreach process and satisfying the phone call requirement. This won't be piloted until August but we are very open to hearing what others are doing and experiencing to reduce hospitalizations.

    Thanks



    ------------------------------
    Sarah C. Overton MSN, RN
    Chief Nursing Officer/VP Clinical Services OSF MultiSpecialty Services
    800 NE Glen Oak Ave
    Peoria, Il 61603
    p. (309)683-7253 c. (309)264-7670 f. (309)624-2834
    "Serving with the greatest care and love"

    www.osfhealthcare.org
    ------------------------------

    Original Message


  • 7.  RE: TCM Calls

    Posted 05-30-2024 09:01

    Hello,

    Is the new process you're looking at an automated call? Thnks!



    ------------------------------
    Ashley Rosa, MSN, RN
    Manager, Ambulatory Care Management
    Bronson Healthcare Group
    Michigan
    ------------------------------

    Original Message


  • 8.  RE: TCM Calls

    Posted 05-30-2024 07:17

    My organization centralized a team who makes these calls for all of our primary care offices. I am the manager of that team and it really does make a great difference in percentage of those calls being completed. We are usually somewhere in the high 70s percent completion with this model (we will never be 100% due to not calling all surgical discharges). I have 56 primary care offices that are covered by a team of 12 staff members (10 LPNs, 2 MAs). They call all medical discharges and high risk surgical discharges. We use Epic and get notified of all discharges into an inbasket.



    ------------------------------
    Nicole McKenzie MSN RN CEN
    Unit Director
    UPMC
    Harrisburg PA
    (717)253-6339
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    Original Message


  • 9.  RE: TCM Calls

    Posted 05-30-2024 09:06

    Hi Nicole,

    What risk score do you use? On average how many calls does each team member complete in a day? Is the inbasket notification better than an ADT report?

    Thank you!

    Ashley



    ------------------------------
    Ashley Rosa, MSN, RN
    Manager, Ambulatory Care Management
    Bronson Healthcare Group
    Michigan
    ------------------------------

    Original Message


  • 10.  RE: TCM Calls

    Posted 05-30-2024 09:14

    The LACE score is used to determine risk for surgical patients. 

    The average varies based on day of the week - the general framework is they can complete 14 patients per day. So, on a Monday they may get assigned 28 patients that need their 2 business day call done by the end of Tuesday. The volumes tend to be less on Tuesday and Wednesday, so they are able to get caught up by the end of Wednesday to be prepared for Thursday and Friday assignments of around 12-14. 

    I have never used an ADT report, so I am not sure if it is better. I like that the process is completely automated and the discharges are automatically sent. 



    ------------------------------
    Nicole McKenzie MSN RN CEN
    Unit Director
    UPMC
    Harrisburg PA
    (717)253-6339
    ------------------------------

    Original Message


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