1. Transitional care management (TCM): A team approach to facilitating transitions of care in a Gerontology Clinic Carol O’Leary, Jeffrey Kochka, Virginia Dolan, Suzanne Salamon, MD, Scot B. Sternberg, MS Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA A teaching hospital of Harvard Medical School The Results/Progress to Date:  When patients were identified at time of discharge, a team-based TCM was successfully implemented for 70-80% of patients in Gerontology  TCM was not completed when patients were cancelled post discharge visit or unable to schedule within 7 to 14-day window required by Medicare  TCM was expanded to include patients discharged from rehabilitation  Patients and families expressed appreciation for the TCM outreach calls and prompt access to visit with their primary care clinician  Data on readmission rates for patients who received TCM services was not available at the time of this report  Non-physician staff (administrative and nurses) can facilitate transitions of care completion of referrals, thus reducing overall administrative burdens on primary care physicians and employing a top of license strategy.  Many patients value the outreach and availability of their care team following discharge, though some patients were unable to attend a visit within timeframe  Continue TCM services.  Assess impact on readmission rates and patient experience.  Implement Chronic Care Management and broader care management strategies within care team.  Transitions of care from a hospital or rehabilitation stay to home present many challenges for patients, particularly for the elderly, and their outpatient care provider.  Patients discharged are at higher risk for discontinuity in care, decompensation, and readmission to the hospital without coordination among care providers and patient.  In 2013, Medicare offered beneficiaries a new covered service, Transitional Care Management (TCM). Licensed providers could be reimbursed for providing TCM services including non-face-to-face outreach to the patient within 2 days of discharge to review their discharge care plan and coordinate services, and a visit within 7-days or 14-days of discharge (depending on medical complexity) to evaluate, provide and manage care.  Implement team-based TCM services for patients in the Gerontology Clinic.  Improve coordination in transitions of care  In collaboration with the Department of Medicine, BIDMC and HMFP compliance and billing, Gerontology developed a plan for the clinic and staff to pilot and roll out TCM services.  Administrative clinic staff, in coordination with providers, designed the process, patient call scripts, and a database for tracking.  In FY2013 Q4, July – September, the Gerontology Clinic piloted TCM services patients discharged from the hospital.  For FY2014, beginning October 2013, TCM services were offered for all patients discharged from the hospital identified by daily discharge reports.  TCM services were further enhanced with the addition of a nurse in the clinic who reviews care plans and medications in more detail with patients.  In June 2014, the Gerontology Clinic expanded TCM services to patients discharged from rehabilitation. Aim/Goal: Problem: Description of the Intervention, including context Results/Findings to date: Key Lessons Learned Next Steps For More Information, Contact Scot B. Sternberg, MS: sbsternb@bidmc.harvard.edu ¹ This initiative has been funded, in part, by a grant from the CRICO patient safety program. ² CRICO (2012) Referral Management Guidelines, developed with contributions by the Referral Management Workgroup (RMW) members