Key Practice Transformation Initiatives

The Practice Transformation Subcommittee has undertaken three primary initiatives to launch the effort. These include:

Annual Wellness Visits. Using the Population Health leadership team’s Annual Wellness Visit guide, the Practice Transformation group devised an Annual Wellness Visit Toolkit for practice medical directors and operational leads. The toolkit helps practices understand what each person in the clinic should do before, during and after an Annual Wellness Visit.

Transitional Care Management. A Journal of the American Medical Association (JAMA) paper analyzed over 18 million TCM-eligible discharges over a three-year period to quantify the impact of compliant TCM services on post-discharge spend, mortality rate, and readmission rates. The post-discharge spend 31-60 days after eligible discharge decreased by 9.7 percent and decreased the post-discharge mortality rate by 0.6 percent.1

CMS offers a billing code for transitional care, which offers a higher reimbursement than a standard 99214 or 99215 visit. The Practice Transformation team sees an opportunity to educate providers on transitional care, helping them become more efficient, provide valuable evidence-based care to their patients and collect the appropriate CMS reimbursement.

Shared Decision-Making. There are opportunities to educate patients about their rights and responsibilities and to ensure end-of-life care conversations take place in the appropriate setting at the appropriate time.

1Source: Bindman AB, Cox DF. Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries. JAMA Intern Med. 2018;178(9):1165–1171. doi:10.1001/jamainternmed.2018.2572