Care Coordination – Transitional Care Management

Associate Director of Quality & Care Coordination: Rachelle Peklinsky, MSN APRN, FNP-BC

Care Coordinators: Terri Mahan RN, Lisa Metts RN, and Heather Swiger, RN 

Care coordination is a critical piece of the Department of Family Medicine PCMH as medicine is changing focus from fee-for-service medicine and turning more towards value-based medicine. The care coordination team consists of a Triage Nurse, Social Worker, Clinical Pharmacist, Dietitian/Certified Diabetes Educator, two Wellness RNs, and three Nurse Case Managers who provide care to patients regardless of payer, based on identified needs and risk. Having this team available within the Department of Family Medicine clinic has proven to be an essential part of the department workflow and clinic dynamic. The Department of Family Medicine has several multidisciplinary clinics which all members of the team participate and offer assistance in their area of expertise.

The Department of Family Medicine case managers offer care coordination services and assist with self-care support, self-efficacy, and behavioral change for the most complex patients in its practice. Though the Department of Family Medicine provides case management and coordination of care for patients regardless of payer, its focus is primarily directed towards the clinic’s high-risk Medicare population by offering Chronic Care Management services.

Chronic Care Management

Chronic Care Management (CCM) is a service offered to Medicare patients with two or more chronic conditions who are at risk for hospitalization, deterioration of function, and/or exacerbation. Focus is placed on enrolling patients who are the highest utilizers (multiple readmissions) and are the sickest based on risk stratification and reporting. The Department of Family Medicine also enroll patients for CCM services during its discharge TCM clinic and through referrals placed by the patient’s PCP with the goal of decreasing admissions and increasing patient access to care. Once verbal consent is obtained, patients are given direct contact information to case management and the triage nurse. They are also given a number to call after hours, should they need assistance. The case managers reach out to these patients once, monthly, to be sure all of their needs are being met and offer education and assistance. The Department of Family Medicine also offer same-day appointment availability, medication reconciliation by clinic pharmacist, coordination of specialist appointments, and monthly outreach to see if the patient has all needs met.

CCM is a time-based service that is reimbursed by Medicare. Medicare covers 80% of the cost of the service, leaving the patient with an approximate $7.00-$15.00 monthly co-pay based on how much time is spent with the patient in non-face-to-face time each month. WV Medicaid and some other Medicare advantage plans have decided to fully cover this service as it adds value and increases quality, because it helps to decrease hospital admissions.

Reimbursement for non-face-to-face time spent with patients is a significant change from the past, and is aiding to reveal the true value of embedded case management within the realm of Family Medicine.

Transactions of Care Management

One of WVU Family Medicine’s case managers also have a dedicated focus on Transitions of Care Management (TCM) services. She focuses on organizing discharge clinic for those patients who have been discharged from the Family Medicine inpatient service. TCM services are also reimbursable for Medicare patients. This case manager performs outreach to patients within two business days and helps to coordinate an outpatient follow up within 7-14 days, post-discharge. She also ensures all discharge instructions have been reviewed with the patient and that he/she received all necessary DME equipment, medication, home health services, etc. after discharge. This service has also added value to the Department of Family Medicine practice because it allows for closer surveillance of its patients who have recently been discharged from the hospital and has assisted in preventing readmissions.

Services Include

  • An interactive contact within 48 hours or by end of 2nd business day after discharge
    • Phone, email, or face-to-face by clinical staff or physician
  • Certain non-face-to-face services
    • Review discharge information
    • Review need or follow-up on pending tests or treatments
    • Interact with other healthcare professionals who will assume care
    • Provide patient, caregiver, or family education
    • Establish referrals and arrange for community resources
  • Licensed clinical staff may furnish non-face-to-face services – MA can work “incident to”
    • Communicate with community services
    • Provide education or self-care support to patient, family, or caregiver
    • Assess and support treatment regimen adherence and medication management
    • Identify available community and health resources
    • Assist patient and family in accessing needed care and services
  • A face-to-face visit
    • Moderate to high decision-making complexity

For more information, please contact Rachelle Peklinsky, MSN APRN, FNP-BC

A photo of Rachelle Peklinsky.

Rachelle Peklinsky, NP

West Virginia University
Nurse Practitioner, Family Medicine