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J Nurs Care Qual. 2018 Oct/Dec;33(4):348-353. doi: 10.1097/NCQ.0000000000000316.

Implementation of a Workflow Initiative for Integrating Transitional Care Management Codes in a Geriatric Primary Care Practice.

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Section of General Internal Medicine (Mss Steckbeck, McBain, and Terrien and Drs Stadler, Stahl and Batsis) and Department of Medical Informatics (Mr Isom), Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire (Drs Stadler, Stahl, and Batsis); Dartmouth Centers for Health and Aging, Dartmouth College, Hanover, New Hampshire (Drs Stadler and Batsis); and Health Promotion Research Center at Dartmouth, Lebanon, New Hampshire (Dr Batsis).


We implemented a transitional care management service led by a nurse care manager. An interdisciplinary team developed a workflow using a Plan-Do-Study-Act cycle for contacting patients. Of the 146 (97.9%) eligible patients, 143 (97.9%) had a phone call within 48 hours. There were 84 of 120 (70.0%) and 117 of 120 (97.5%) attendance rates of those attending visits within 7 and 14 days. A care manager-led workflow was successfully and easily implemented within a primary care practice.

[Available on 2019-10-01]
[Indexed for MEDLINE]

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