Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary Care Practice.
Julia Steckbeck, Christi McBain, Kerry L Terrien and 4 others
PMID 29271832WHAT IT FOUND
A new workflow for geriatric primary care achieved 97.9% phone contact within 48 hours of discharge and 97.5% follow-up visits within 14 days.
The team also identified 92.7% correct billing documentation, generating additional revenue for existing care.
Key findings
01Phone calls were initiated and completed within the designated 48-hour period for 97.9% of eligible patients.
02Of patients who checked in for appointments, 97.5% were seen within the 14-day window.
03Audited encounters showed 92.7% had appropriate documentation for billing.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
This is a single-site quality improvement project, not a randomized controlled trial, so it cannot prove that the workflow caused better health outcomes. The study did not measure readmission rates or patient health status changes, only process metrics like call completion and billing accuracy. The population was limited to one geriatric practice in a rural area, which may not reflect urban or different healthcare systems. The authors note that the study was not reviewed by an Institutional Review Board because it was a process improvement initiative.
Declared interests
The authors declared no conflicts of interest. Funding was provided by the National Institute on Aging and the Centers for Disease Control and Prevention.
The easy way to misread this
Do not interpret the high phone contact and visit rates as evidence that this workflow reduces hospital readmissions or improves patient health. The study measured process compliance and billing accuracy, not clinical outcomes like readmission rates.