Apr 1, 2024

Follow-up care after hospitalization

The first seven to 30 days following hospital discharge can be an overwhelming transition for patients. Keeping track of follow-up appointments, new medications, changes to existing medications, and overall recovery can be difficult to navigate for many. Partnership with the primary care provider during the immediate post-discharge period is integral to prevent readmission and ensure patients have the smoothest transition out of the inpatient setting.

Quality measure focus: Transitions of Care (TRC)

This measure focuses on four components integral to a successful transition from the inpatient setting:

  1. Notification of inpatient admission (through two days)
  2. Receipt of discharge information (through two days)
  3. Patient engagement after inpatient discharge (within 30 days)
  4. Medication reconciliation post-discharge (within 30 days)

Quality improvement guidance

  • Evaluate how your practice currently receives admission and discharge notifications from local hospitals. If you find your practice is missing notifications from a certain facility, it may be helpful to reach out to the facility to ensure that they have updated fax and contact information.
  • Ensure any faxed notifications of admission or discharge are saved and scanned into the member’s medical record.
  • Evaluate your practice’s current workflows around engagement with a member after they have been hospitalized. Do you have any staff dedicated to patient outreach after hospital discharge? Are they prepared to provide a quality-informed interaction? Consider providing nurse care managers or staff responsible for post-discharge follow-up training on the TRC measure and its requirements.
  • When reviewing medications after discharge, ensure the medication reconciliation is clearly documented in the medical record.

Codes to identify medication reconciliation: 

  • CPT Codes: 99495, 99496 
  • CPT Category II Codes: 1111F (Discharge medications reconciled with the current medication list in outpatient medical record)

Codes to identify transitional care management services: 

  • CPT Codes: 99495, 99496

Please reach out to the Quality Concierge Team at QualityHEDIS@bcbsri.org to explore available resources.