Implementation of Timely and Effective
Transitional Care Management Processes
Tuesday, March 21, 2023
3:00-4:00pm Eastern / 12:00-1:00pm Pacific
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Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be available
after the end of the series, Summer 2023.
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Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would
be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation
(not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or
that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-governmental
sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an
endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
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At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
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National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity sessions,
trainings, research, publications, etc.
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Speakers
• Mary Blankson, DNP, APRN, FNP-C, FAAN
• Chief Nursing Officer, Community Health Center, Inc.
• Veena Channamsetty, MD, FAAFP
• Chief Medical Officer, Community Health Center, Inc.
• Bibian Ladino-Davis
• Behavioral Health Coordinator, Community Health Center, Inc.
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Objectives
• Describe processes for following up on ER visits and hospital discharges, including
roles and responsibilities
• Discuss a best practice for centralized notification of ER visits and hospitalizations
• Review other use cases for managing centralized notifications of hospital events:
• Risk stratification and management - Integrated Care Team Meetings
• Report of death of a patient and caring for the family
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Areas Identified as Opportunities
• Prior to 2016 - Decentralized sources of data where notification of ER visits and
hospitalizations was provided to care teams directly through discharge
notifications and ER visit notes, rather than a central source disseminating the
information with robust processes
• Standardized processes for reporting death of a patient
• Consistency around Integrated Care Meetings to support our most complex
patients
• Standardized workflows to update and document in the EHR with regard to care
transitions
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Daily Follow-up on ER Visits and Discharges
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Daily Follow-up on ER Visits and Discharges
• CHC processes have evolved over time to reflect our priorities as well as our evolving
understanding of our patient population and their use of the ER and hospital.
• Overview: The BI Department sends a list of CHC patients to Bamboo Health on a monthly basis
who have had a medical visit in the last 12 months OR who are on a Value Based Roster regardless
of last visit date.
• This ensures that we are notified if a patient visits a hospital for an ER visit or admission.
• While Bamboo Health has an app that some groups use to manage their patient workflow in the
hospital, we instead ingest a file with that information on a daily basis so that a file with a list of
patients is distributed each morning.
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Daily Follow-up
on Hospital Discharges
Triage nurses call each patient who meets
certain criteria (e.g., Value Based Roster patient,
specific dx, etc.) and, using a structured
template, ask the patient a series of questions:
1. Why were you hospitalized?
2. How are you feeling today?
3. Were you discharged with any new meds to take
at home? If yes, what are they?
4. Do you have any nurses or therapists visiting you
at home?
5. Were you told to schedule appointments with any
doctors besides your primary care provider? If yes,
who?
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• Nurses make up to three attempts to reach the patient by
phone. Note: Bamboo Health does at times, provide a new
phone number for the patient based on what the patient
reported at the hospital and this can be valuable!
• This same list of patients is also sent to the MA and they
retrieve the hospital discharge note and scan into chart.
• Our follow up rates are about 54% which is well above the
rates for other health centers in our state (43%) and the
Medicaid rate of 38.5%.
• This information can be reviewed by the provider during the
post-hospital visit.

Daily Follow-up
on Hospital Discharges
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Other uses of Hospital Discharge
Information
1. Complete SDoH (PRAPARE) with patients who had a hospital
discharge by the Triage Nurses.
2. Mail a congratulations card to new moms upon the notification of
a birth.
3. Alert in NOVO so that if a patient was high risk/who met certain
criteria (e.g., multiple ER visits; recent hospitalizations; high risk
score) the PSA would delegate the call to Triage to talk with
patients.

Daily Follow-up on ER Visits
• MA reviews the list and notifies PCP of any ER visits that require follow up
• Other uses of ER information
1. For pediatric patients with an ER visit for asthma, a text message is sent to
the patient to encourage them to schedule follow up with PCP (if a visit is not
already scheduled)
2. For patients in a value based program that requires complex care patients
who meet certain criteria to have follow up we send a text message to
patient to schedule follow up visit
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ER Discharge Follow Up

Best Practices
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Bamboo Health Process
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• All patients in a Value Based Program
• All patients who are discharged for COPD, Diabetes, Asthma, Hypertension, Delivery of
newborn, Poisoning; F code (all BH diagnoses)
Consider whether there are sufficient resources to follow up on all
hospital events. Prioritizations may include:
Other considerations

Special Considerations
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Patients who have not been
seen in the last 3 years
School Based Health Center
patients who do not have
CHCI as their PCP
Other opportunities – upon
patient admission to ER or
hospital

Report of Death of a Patient Process
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Notification
of a Patient Death
• Weekly report of patients who, according to Bamboo Health, have passed away the prior
week AND/OR whom we were notified about a patient’s passing.
• The report includes:
• Patient ID and Name
• Date of passing
• Hospital/facility
• PCP
• PCP Site
• The report is disseminated to the Operations Managers, Senior Program Manager for
Population Health and the Senior VP/Clinic Director.

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Response upon Learning
of the Death of a CHC Patient
Procedure addresses:
• Sympathy Calls or Cards
• Ensure family members are supported
• Opportunity to offer further supportive services
• Clarity on when calling family members is appropriate
• Deactivation of the Patient Chart:
• Ensures canceling of follow up calls and reminders
• Updates the E.H.R status

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Response upon Learning
of the Death of a CHC Patient
Sympathy Calls or Cards to Family Member
AND
Contacting the family member would NOT be inconsistent with any prior expressed preference of the patient.
Either:
The family member was involved in a supportive and
positive manner in the patient’s care per the
professional judgment of the patient’s provider, or
The patient signed a Permission to Share form
allowing CHC to communicate with the family
member about the patient’s care;
Provider may call or send a written communication to the patient’s family member to
express sympathy if all of the following criteria are met:

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Response upon Learning
of the Death of a CHC Patient
Deactivation of the Patient Chart
1. The staff person who is notified creates a telephone encounter (TE) with reason of “Report of
Death”. TE is sent to site’s Operations Manager (OM).
•The Provider or OM may enter details of the patient’s passing.
•Information must include the date of passing
•TE serves as documentation of passing.
2. OM cancels all future appointments and suppresses all recalls
3. IF TE was not generated by PCP, OM assigns TE to PCP as FYI
•PCP may assigns to relevant BH or Dental provider if applicable for review/FYI
•PCP/BH/Dentist assigns back to OM
4. OM updates the patient records as “deceased” to inactivate the patient’s chart
5. Any documentation about the patient death is scanned into patient record by the OM
6. OM marks TE as addressed

Integrated Care Team Meetings
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Integrated Care Team Meetings
• The purpose of the Integrated Care Meeting (ICM) is to coordinate a
comprehensive plan to address risk factors impacting the health and
well-being of our patients. Input from all team members is shared at
these meetings to support optimal patient outcomes.
• A dedicated Behavioral Health Coordinator is responsible for
coordinating ICM at every site once a month for patients identified as
high risk who would benefit.
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Integrated Care Meeting:
CHC Criteria for Patient Selection
• Patients with a high risk score who have a PCP and BH Provider in common
• Patients with recent hospital discharges or ER visits
• Patients with recent discharge for BH diagnoses
• Patients identified by PCP
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Integrated Care Meetings
• 7 to 10 ICMs are held per month at different sites
• 3 to 9 patients discussed at each ICM
• PCP, BH Provider, Nurse, MA and other staff are present with
psychiatric providers attending as feasible
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Patient
Primary
Care Provider
Behavioral
Health Provider
RN and/or MA
Behavioral Health Care
Coordinator
Patient Case Study
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• PCP Report:
• Alcohol use disorder
• Morbid obesity and is medically fragile
• Behavioral Health Provider Report:
• Last seen in therapy 4 months prior and recommended the patient return to therapy.
• Auditory hallucinations, depression, anxiety and inconsistent part of suboxone program.
• Recent hospitalization for chronic alcoholism, cardiac problems, seizures
• RN and/or MA Report:
• Patient due for any vaccines, labs, or DIs
• Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.)
• Behavioral Health Care Coordinator:
• Patient declined SDOH screening
• As a result of the ICM, the patient was referred to CHW and outreach to patient to
reengage in therapy.
• Information about medications prescribed outside of CHC by external provider, added to
medication list by Pharmacy Team
• Collaboration between CHW and RN resulted in a motorized wheelchair for the patient
Patient
Primary
Care
Provider
Behavioral
Health
Provider
RN
and/or
MA
Behavioral
Health Care
Coordinator
Patient
Case Study 1
The Patient:
•45 year old male who is cared for at our homeless shelter site
•Selected for discussion because of his high risk score (11.4, where 1.0 is the average risk score) from the payor.
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• PCP Report:
• Reported the patient had a history of osteoporosis, cannabis use disorder and memory
problems.
• Behavioral Health Provider Report:
• Patient had PTSD; anxiety, borderline personality disorder and major depression.
• Engaged in therapy (last seen the week prior) but BH provider indicated patient would
benefit from a higher level of care.
• Patient prefers to stay with CHC given the time going to IOP would be too much. The
patient was also engaged with psychiatry at CHC.
• RN and/or MA Report:
• Patient due for any vaccines, labs, or DIs
• Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.)
• Behavioral Health Care Coordinator:
• Patient completed SDOH screening
• The patient was referred to a CHW to support visit adherence.
• Patient presented to PCP differently than to BH provider. Essential to have the discussion
with all members of the care team.
• Identified free transportation program to ensure access to the site.
Patient
Case Study 2
The Patient:
•63 year old female selected for ICM b/c high risk score, 11.4.
Patient
Primary
Care
Provider
Behavioral
Health
Provider
RN
and/or
MA
Behavioral
Health Care
Coordinator
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Today's presentation covered ...
• The processes for following up on ER visits and hospital discharges
• A Best practice for centralized notification of ER visits and hospitalizations
• Managing centralized notifications of hospital events:
• Integrated Care Team Meetings for risk stratification and management
• Report of death of a patient and caring for the family
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Questions?
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Contact Information
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For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca