General Recommendations For Practices:
- Identify your patients at higher risk of ER visits, hospitalizations, and rehospitalizations due to chronic conditions.
- Educate patients to recognize symptoms of preventable events, empower them with self-management tools and make sure they are able to schedule follow-up appointments with their PCP.
- Inform patients about access to providers after hours (availability during evenings and weekends).
- Encourage patients to contact their PCP immediately upon feeling ill to avoid unnecessary ER visits.
- Ensure PCP staff is knowledgeable regarding which clinical events are true emergencies.
- Identify patients discharged from ER or hospital through available portals and schedule within 7 days for a clinical follow-up and medication reconciliation.
- Listen to patient experience and evaluate barriers such as social determinants of health.
- Consider the need for Care Management referral (SOMOSCareManagement@evolenthealth.com).
For inquiries and concerns, please email quality@somosipa.com.
Transition of Care Best Practices:
All patients 18 years and older must have a follow-up service within 7-14 days of facility discharge. The provision of care can be fulfilled via face-to-face or Telehealth visit. Use the following codes:
CPT: 99496 (Follow-up Transition of Care 7 days), 99495 (Follow-up Transition of Care 14 days).
Make sure you have access to admissions, discharges and transfers (through EMR or other population health tools).
Prioritize same-day appointments for patients who were recently discharged.
Assign team a member to call patients within 48 hours of discharge to schedule follow-up and request discharge summary.
Send appointment reminders and reschedule missed appointments as needed.
Patient must be seen within 7-14 days of discharge and must not be readmitted within 30 days.
During the post-discharge follow-up visit, complete the following:
- Ask what factors led to hospitalization
- Review discharge summary
- Reconcile discharge medications with current outpatient regimen
- Determine need for follow-up care (medication changes, testing, appointments)
- Instruct patient in self-management by having them repeat back and write down instructions
- Consider referral to Care Management
For inquiries and concerns, please email quality@somosipa.com
Hospital Inpatient Prevention Quality Indicators – Pediatrics (PDI):
High-quality outpatient care should prevent avoidable hospital admissions for pediatric patients due to the following: Asthma, diabetes, gastroenteritis, urinary tract infection.
Patients with these conditions and a recent ER visit or admission should be seen within 7-14 days of discharge and must not be readmitted within 30 days. Consider quarterly appointments to ensure the condition is managed, the care plan is working, and medication adherence is consistent.
PDI Tips:
- Set quarterly appointment tracking for patients with these conditions
- Recommend pharmacy home-delivery service for patients who have trouble getting their medication
- Encourage participation in Care Management to parents or guardians of pediatric patients with asthma
- Consultation with asthma specialist is highly recommended for any child with ER visit or hospitalization for asthma
- Collaborate with pharmacists to keep conditions well managed
- Consider referral to Care Management
Additional Quality Indicators Linked to Transitions in Care
Hospital Inpatient Prevention Quality Indicators – Adults (PQI):
High-quality outpatient care should prevent avoidable hospital admissions for adult patients due to the following: Asthma, bacterial pneumonia, chronic obstructive pulmonary disease, diabetes (short-term or long-term complications, uncontrolled diabetes, or lower-extremity amputation), hypertension, heart failure, and urinary tract infection.
Patients with these conditions and a recent ER visit or admission should be seen within 7-14 days of discharge and must not be readmitted within 30 days. Consider quarterly appointments to ensure the condition is managed, the care plan is working, and medication adherence is consistent.
PQI Tips:
- Set quarterly appointment tracking for patients with these conditions
- Recommend mail-order or home-delivery service to patients who have trouble getting to their pharmacy
- Collaborate with pharmacists to help keep conditions well managed
- Consider referral to Care Management
For more information, please contact your Practice Transformation Associate (PTA) or email ProviderRelations@somosipa.com
