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Research ArticleFamily Medicine and The Health Care System

Evaluation of a Family Medicine Transitional Care Service Line

Bryan Farford, Sally Ann Pantin, John Presutti and Colleen S. Ball
The Journal of the American Board of Family Medicine July 2019, 32 (4) 619-627; DOI: https://doi.org/10.3122/jabfm.2019.04.180272
Bryan Farford
From the Department of Family Medicine, Mayo Clinic Florida, Jacksonville, FL.
DO
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Sally Ann Pantin
From the Department of Family Medicine, Mayo Clinic Florida, Jacksonville, FL.
MD
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John Presutti
From the Department of Family Medicine, Mayo Clinic Florida, Jacksonville, FL.
DO
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Colleen S. Ball
From the Department of Family Medicine, Mayo Clinic Florida, Jacksonville, FL.
MS
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  • Article
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References

  1. 1.↵
    CMS.gov. 2015 measure information about the 30-day all-cause hospital readmission measure, calculated for the value-based payment modifier program 2015. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-ACR-MIF.pdf. Accessed May 27, 2018.
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    Innovation.CMS.gov. 2014. Available from: https://innovation.cms.gov/Files/reports/patient-safety-results.pdf. Accessed May 27, 2018.
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    RWJF.org. The revolving door: A report on U.S. hospital readmissions. 2013. Available from: https://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404178. Accessed May 27, 2018.
  4. 4.↵
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    . Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med 2010;5:392–7.
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    1. Moore C,
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    3. Williams S,
    4. McGinn T
    . Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646–51.
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    1. Forster AJ,
    2. Murff HJ,
    3. Peterson JF,
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    . The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161.
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    3. Orav EJ,
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    . Readmissions, observation, and the hospital readmissions reduction program. N Engl J Med 2016;374:1543–51.
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  8. 8.↵
    CMS.gov. Readmissions Reduction Program (HRRP)—Centers for Medicare & Medicaid Services. 2018. Available from: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed May 27, 2018.
  9. 9.↵
    CMS.gov. Frequently asked questions about billing the Medicare physician fee schedule fortransitional care management services. March 17, 2016. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf. Accessed May 27, 2018.
  10. 10.↵
    CMS.gov. Transitional care management services. December 2016. Available from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Text-Only.pdf. Accessed May 27, 2018.
  11. 11.↵
    1. White B,
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    . Reducing hospital readmissions through primary care practice transformation. J Fam Pract 2014;63:67–73.
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    1. Hitch B,
    2. Parlier AB,
    3. Reed L,
    4. et al
    . Evaluation of a team-based, transition-of-care management service on 30-day readmission rates. N C Med J 2016;77:87–92.
    OpenUrlAbstract/FREE Full Text
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The Journal of the American Board of Family     Medicine: 32 (4)
The Journal of the American Board of Family Medicine
Vol. 32, Issue 4
July-August 2019
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Evaluation of a Family Medicine Transitional Care Service Line
Bryan Farford, Sally Ann Pantin, John Presutti, Colleen S. Ball
The Journal of the American Board of Family Medicine Jul 2019, 32 (4) 619-627; DOI: 10.3122/jabfm.2019.04.180272

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Evaluation of a Family Medicine Transitional Care Service Line
Bryan Farford, Sally Ann Pantin, John Presutti, Colleen S. Ball
The Journal of the American Board of Family Medicine Jul 2019, 32 (4) 619-627; DOI: 10.3122/jabfm.2019.04.180272
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Keywords

  • Patient Discharge
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  • Quality Improvement
  • Transitional Care

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