Transitions of Care

Transitional care provides primary care coverage to patients for the 30 days after discharge from an inpatient, behavioral health or skilled nursing facility. Interactive outreach supported by the TOC worklist is the first step in preventing unnecessary complications, such as medication errors or unmet communication needs. Discharge focused face to face visits are then scheduled and have a direct impact on improving patient outcomes, reducing preventable hospital readmissions, and reducing financial waste.

After each hospitalization, patients are at risk for serious health complications. High quality Transitional Care reduces the risk for complications, and improves the post-discharge experience for both the patient and the practice.

Foundational Materials

Foundational learning is for newcomers to this topic and the Aledade App. These materials provide a general overview to the topic and go on to explore performance measurement, practice workflow transformation, and App use.

Transition of Care Worklist Overview

Learn how the Aledade App tracks TOC through the TOC Worklist and the Daily Huddle and how these features help practices reach out to patients throughout the sensitive post-discharge timeframe.

Select training format:

Slide Version

Supporting Guides and Resources:

Transitions of Care Admission, Discharge, and Transfer Report User Guide

Transitions of Care Call Outcomes Guide

Transitions of Care Worklist User Guide

Incorporating Care Transitions into Practice Workflows

Learn about the staffing, planning, and revenue cycle management necessary for successful Transitions of Care (TOC) workflows, given the complexity of post-discharge care.

Select training format:

eLearning

Slide Version

Supporting Guides and Resources:

Best Transitional Care Management (TCM) Service Workflow Checklist

Transitional Care Management (TCM) High Level Workflow

Transitional Care Management Goals Worksheet

Transitional Care Management Support Staff Roles & Responsibilities List

The Importance of Transitions of Care

Learn about how Transitional Care Management (TCM) and Transitions of Care (TOC) visits support value-based care through reducing hospital readmissions.

Select training format:

eLearning

Slide Version

Supporting Guides and Resources:

TCM Practice Waiting Room Sign (Patient-facing)(Editable)

TOC/TCM Benefits Backed by Research

Transition of Care Performance and Measurement

Learn about the similar goals and workflows Transitions of Care (TOC) and Transitional Care Management (TCM) share as well as their different billing and documentation.

Select training format:

eLearning

Slide Version

Supporting Guides and Resources:

Discharges Eligible for Transitional Care Management Services Guide

TCM Illustrative Guide to Outreach and Billing

Transitions of Care vs. Transitional Care Management Billing Guide

Transitional Care Management (TCM) Workflows

Learn the basics of billing, required components, staffing models, and frequently asked questions related to Transitional Care Management (99495/6)

Select training format:

eLearning

Slide Version

Supporting Guides and Resources:

Transitions of Care Calendar Handout (PDF)

Transitions of Care (TOC) and Transitional Care Management (TCM) Visit Components and Patient Outreach Strategies

Gain an overview of the different types of transitional care visits and learn strategies for conducting effective outreach to patients in need of care transition support.

Select training format:

eLearning

Slide Version

Supporting Guides and Resources:

Outreach Documentation Template

Sample Transitional Care Management Outreach Interaction Script

TCM Overcoming Challenges with Patient Engagement

Transitional Care Management Outreach EHR Components Template (PDF)

Transitional Care Management Workflow for Missed Appointments

Workflow for Patients Declining the Transitional Care Management Visit

Intermediate Materials

Intermediate learning is for learners with experience on this topic and the Aledade App. These materials can enhance practice workflow efficiency and maximize App utilization.

Leveraging Transitions of Care (TOC) Visits to Promote Better Patient Care

Learn the importance of TOC visits for all patients, across payers. Identify how TOC visits provide opportunities to address social determinants of health and comprehensive advanced care planning.

Select training format:

Slide Version

Medical Decision-Making and Transition of Care Payer Quality Measures

Learn how Aledade tracks TOC performance, how TOC visits support quality performance, and how to measure decision making for EM and 99495/6 visits.

Select training format:

Slide Version

Supporting Guides and Resources:

Discharges Eligible for Transitional Care Management Services Guide

Medication Reconciliation in Transitions of Care (TOC) Visits

Learn about how medication reconciliation is a key element of Transitions of Care since it empowers patients through education and collaborative review of their care plan.

Select training format:

eLearning

Slide Version

Supporting Guides and Resources:

Medication Reconciliation Post-Discharge Overview

Understanding Data and Priortization in the TOC Worklist

Learn how to implement workflows around the “confirm discharge” categorization, patient prioritization, and an advanced understanding of the Ambulatory/Discharge/Transfer data flow into the Aledade App.

Select training format:

Slide Version

General Materials

We do not have any of these materials at this time.