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Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary Care Practice.


ABSTRACT: 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.

SUBMITTER: Steckbeck J 

PROVIDER: S-EPMC6013313 | biostudies-literature | 2018 Oct/Dec

REPOSITORIES: biostudies-literature

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Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary Care Practice.

Steckbeck Julia J   McBain Christi C   Terrien Kerry L KL   Isom David D   Stadler Daniel D   Stahl James E JE   Batsis John A JA  

Journal of nursing care quality 20181001 4


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. ...[more]

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