Care Coordination During Inpatient or Sub-Acute Encounter

Practice staff wants to help coordinate care while their patient is hospitalized or at a sub-acute treatment facility. This could include providing support or information to hospital/facility staff, and potentially avoiding hospital admission or reducing length of stay. 

  1. Submit panel to CRISP in one of the following ways:
    a.   Self-service panel loader.
    b.   Manual submission on a bi-weekly basis (via secure e-mail or sFTP).
    c.   Auto-subscribe via ADT integration.
  2. Receive Alerts via CRISP Encounter Notification Service (CRISP Direct, ENS PROMPT, Census View, DocHalo, etc.) for the following encounters:
    a.   ED admissions and discharges.
    b.   Inpatient admissions and discharges.
    c.   Skilled nursing facility admissions and discharges.  
  3. Review encounters daily, or more than once a day.
    a.   Identify the patient as complex using clinical judgement or past hospitalizations
          and ED visits listed with notification. 
  4. High Risk Encounters: Contact the treatment facility to speak with the Care Team regarding the patient’s condition and provide pertinent clinical information and prevent an avoidable admission.
  5. When patient is discharged, refer to workflow for Transitional Care Management.

Transitional care management (post-discharge)

Practice staff can identify patients who have been discharged from hospital-based care. The physician can support her patients’ safe transitions from inpatient hospital settings. 

  1. Submit panel to CRISP in one of the following ways :
    a.   Self-service panel loader.
    b.   Manual submission on a bi-weekly basis (via secure e-mailor sFTP).
    c.   Auto-subscribe via ADT integration. 
  2. Receive Alerts via CRISP Encounter Notification Service for the following encounters :
    a.   ED admissions and discharges.
    b.   Inpatient admissions and discharges.
    c.   Skilled nursing facility admissions and discharges.  
  3. Review encounters daily, or more than once a day. 
  4. When a patient is discharged from the ED: Call patient to check on status, do medication reconciliation, understand discharge instructions, and assist as necessary. 
  5. When a patient is discharged from an Inpatient Stay: Call patient to check on status, do medication reconciliation, understand discharge instructions, and assist as necessary. Also, schedule an appointment within 7 days of discharge in accordance with Transitional Care Management billing guidelines.
    a.   https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
          MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-
          Fact-Sheet-ICN908628.pdf
     
  6. Prior to transitional care face-to-face appointment, refer to workflow for Pre-Visit Planning and Patient History.