The Role of the Transitional Care Management Pharmacist

Ineffective transitions of care are a huge expense for the health care industry, even more so if the patient’s readmitted in the 30-day postdischarge window. It is estimated that Medicare pays $15 billion each year to cover the costs of readmissions, of which $12 billion is for cases considered preventable.¹

In an effort to better identify these preventable readmissions, Medicare created 2 new codes, 99495 and 99496, which are reimbursable for non-face-to-face and face-to-face transitional care coordination services. The US Centers for Medicare and Medicaid Services (CMS) require 2 main objectives to bill using these codes:

1. A non-face-to-face patient contact within 48 hours postdischarge.

2. A face-to-face office visit 7 to 14 days postdischarge.

Code selection is determined by the amount of time the patient is seen face-to-face postdischarge (7 or 14 days) and the medical decision-making complexity of the service. The codes can be used following care from an inpatient setting (including acute hospital, rehabilitation hospital, or long-term acute care hospital), partial hospitalization, observation status in a hospital, or skilled nursing facility/nursing facility.²

CMS classifies 48-hour non-face-to-face services as those provided under the general supervision of a physician by licensed clinical staff. A clinical staff member is defined as someone who works under the supervision of a physician or other qualified health care professional and is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but doesn’t individually report it.³

Opportunities exist for pharmacists working under collaborative practice agreements to provide these non-face-to-face services under the general supervision of a physician. Reaching out into my network, I identified a pharmacist who offers this service and coordinates care transitions.

As part of a rural health clinic in Magnolia, Arkansas, Lauren Glaze, PharmD, works very closely with case managers in local hospitals and rehab facilities. Each workday, she goes through a list sent by the case managers that identifies patients who have undergone a transition of care. Once identified, Dr. Glaze proceeds to complete the non-face-to-face initial patient contact within 2 business days.

During the call, the coordinating pharmacist reviews the patient’s medications, identifies changes or discrepancies in medications, counsels on proper use of new medications, reinforces the importance of the new regimen, identifies the need for additional tests or lab work, and determines whether there are procedures or referrals ordered for the patient.

Ideally, the transitional care management (TCM) pharmacist is also present during the patient’s face-to-face visit to assist with any medication reconciliation or medication-related issues. The services have been very beneficial to the rural health clinic, and as Dr. Glaze noted, “they are seeing less readmissions and decreases in patients requiring transitions of care.”

Readmission rates are influenced in large part by factors outside of the hospital domain, including poor social support and access to outpatient care.⁴ Pharmacists are no stranger to this predicament and know their assistance can help impact these outside factors.

Pharmacists serve as an interesting pivot point for patients undergoing transitions of care. They’re also being used on the front end of the care transition workflow cascade by being placed in emergency rooms and hospital settings. There, they may perform services like initial home medication reconciliation documentation and identifying patients who at high risk for adverse drug events.

Pharmacist Tamar Lawful, PharmD, is a transitions of care clinical pharmacist at Community Regional Medical Center in Fresno, California, where she put together a “Meds-to-Beds” program. Patient eligibility is determined by whether they’re ordered a high-risk medication before admission and whether their insurance is contracted with the hospital’s outpatient pharmacy, among other factors.

After examining the program’s impact of the transitions of care pharmacy service on 30-day readmission rates over a 3-month period, Dr. Lawful found readmission rates for Meds-to-Beds patients decreased by 29%, versus an increase of 12% for comparable patients. There was a projected yearly cost savings of approximately $780,000 in her small 124-patient study.

Independent pharmacy consultants are also stepping up to offer transitional care services and are noticing a market need for TCM coordinators.

References

1. Hostetter M, et al. Avoiding preventable hospital readmissions by filling in gaps in care: the community-based care transitions program. Commonwealth Fund. commonwealthfund.org/publications/newsletters/quality-matters/2012/august-sept/in-focus. Published September 2012.

2. American College of Physicians. What practices need to know about transition care management codes. acponline.org/practice-resources/business-resources/coding/general-coding-resources/what-practices-need-to-know-about-transition-care-management-codes.

3. Texas Medical Association. Medicare chronic care management: who can bill for service? texmed.org/Template.aspx?id=33757. Published May 27, 2015.

4. Rennke S, et al. Transitional care strategies from hospital to home: a review for the neurohospitalist. Neurohospitalist. 2015;5(1): 35-42.