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Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary
Julia Steckbeck1, Christi McBain, Kerry L Terrien
1Section of General Internal Medicine (Mss Steckbeck, McBain, and Terrien and Drs Stadler, Stahl and Batsis) and Department of Medical Informatics (Mr Isom), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire (Drs Stadler, Stahl, and Batsis); Dartmouth Centers for Health and Aging, Dartmouth College, Hanover, New Hampshire (Drs Stadler and Batsis); and Health Promotion Research Center at Dartmouth, Lebanon, New Hampshire (Dr Batsis).
None:
We implemented a transitional care management service led by a nurse care manager. An interdisciplinary team developed a workflow using a Plan-Do-Study-Act cycle for contacting patients. Of the 146 (97.9%) eligible patients, 143 (97.9%) had a phone call within 48 hours. There were 84 of 120 (70.0%) and 117 of 120 (97.5%) attendance rates of those attending visits within 7 and 14 days. A care manager-led workflow was successfully and easily implemented within a primary care practice.
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