Standardization of Transition Care Management (TCM) Workflow in a Safety Net Hospital Increases Percentage of Completed TCM, Increases Revenue and Decreases Hospital Readmission

The Centers for Medicare and Medicaid Services (CMS) in 2013 began offering payment to ambulatory practices for the transitional care management (TCM) service to address readmission rates. The adoption of a successful TCM model is needed to improve patient outcomes and lower readmission rates. At UF Health Jacksonville, we formed a dedicated TCM team whose role was exclusive to the completion of the TCM non-face-to-face process (NF2F). The team elected to utilize the Define, Measure, Analyze, Improve, and Control (DMAIC) model as the process improvement methodology to guide the project. UF Health Jacksonville has eliminated many of the barriers facing Academic Center Safety-net Hospitals as it relates to readmissions by implementing this approach. After the implementation of the dashboard and all of the improvements, there was an immediate return on investment increase of 81.06 percent exceeding the projected goal of 75 percent and decrease in readmission rate to as low as 5 percent.