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On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. To learn more about this from Change Healthcare, please visit the Change Healthcare website or reach out to the contact center at 1-866-262-5342. More from Change Healthcare
On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. To learn more about this from Change Healthcare, please visit the Change Healthcare website or reach out to the contact center at 1-866-262-5342. More from Change Healthcare

TRC - Transition of Care

Medicare members 18 yrs of age or older who had a recent inpatient admission.

Exclusions: Members who use hospice services or elect to use a hospice benefit any time during the measurement year. Members who die at anytime during the measurement year.

Inpatient Engagement:

  • Buckeye’s Team will send via fax notification of your patient’s admission including information on the admitting facility, date of admission, anticipated date of discharge (as applicable), primary diagnosis, and the level of care. No Level of care included.

Receipt of Discharge Information:

  • Buckeye’s Team will send via fax notification of your patient’s discharge including the discharge instructions, a medication review, the care plan, and the RN CM’s contact information for any follow up questions or concerns- if available at discharge.

Patient Engagement:

  • Buckeye’s Care Management team will follow up with the patient to assist in scheduling a follow up visit following their IP admission.

Medication Reconciliation:

  • Buckeye’s Care Management team will complete a medication reconciliation and fax to your office to include in the patients record.
    MEASUREDEFINITIONWHAT TO EXPECTPCP FOLLOW-UP

    Notification of Inpatient Admission.

     

    Documentation of receipt of notification of inpatient admission

    on the day of admission through 2 days after the admission. (3 total days)

    		Buckeye’s Team will send via fax notification of your patient’s admission including information on the admitting facility, date of admission, anticipated date of discharge (as applicable), primary diagnosis, and the level of care.

    PCP office to document member inpatient stay in records.

    Receipt of Discharge Information.

     

    Documentation of receipt of discharge information on the day of

    discharge through 2 days after the discharge. (3 total days)

    		Buckeye’s Team will send via fax notification of your patient’s discharge including the discharge instructions, a medication review, the care plan, and the RN Care Manager’s contact information for any follow up questions or concerns.

    PCP office can contact the RN Care Manager with any questions or concerns.

     

    PCP office may receive medical record documentation request of receipt of discharge information from Health Plan.

    Patient Engagement After Inpatient Discharge.

     

    Documentation of patient engagement (e.g., PCP office

    visits, visits to the home, telehealth) provided within 30 days after discharge. (31 total days)

    Buckeye’s Care Management team will follow up with the patient to assist in scheduling a follow up visit following their IP admission.

     

    PCP office to ensure follow up visit post discharge from inpatient facility occurs within 30 days of discharge.

     

    PCP to submit claims timely for office visit to Health Plan.

    Medication Reconciliation Post-Discharge.

     

    Documentation of medication reconciliation on the date

    of discharge through 30 days after discharge. (31 total days)

    		Buckeye’s Care Management team will complete a medication reconciliation and fax to your office to include in the patients record.

    PCP to review medication reconciliation for patient records and include in the patient’s record.