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This initiative aimed to enhance the post-discharge process to improve care quality and reduce missed follow-ups.Methods:We implemented a streamlined follow-up process for stroke patients discharged home, aligning with the Centers for Medicaid and Medicare (CMS) definition of the Transitional Care Management (TCM).
This initiative, led by Advanced Practice Providers (APPs), aimed to refine the post-discharge process to enhance care quality and reduce missed follow-ups.Methods:We introduced a streamlined follow-up process for stroke patients discharged home, adhering to the Centers for Medicaid and Medicare (CMS) Transitional Care Management (TCM) model.
Programs receive a set amount monthly from Medicare and Medicaid to provide nearly everything for people over 55 whose needs qualify them for a nursing home but who don’t want to enter one. This may allow the PACE plan to adjust risk scores and potentially increase reimbursement per participant.
In addition to this, the Medicaid EHR Incentive Program aims to encourage healthcare providers to adopt and effectively use certified Health IT to improve patient care information exchange. Additionally, the 2024 final rule retains the methodology for measuring scores and achieving points with no notable alterations.
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