Article Sections
Transitions Tab Overview
From the Transitions tab landing screen, users are provided a compiled list of the patient's transition history, transition-specific functionality, and the option for creating new transition records.
Transitions Table
All of the patient's documented TCM records are listed in a table format, with the most recent transition record positioned at the top.
Status: Designates where the transition currently falls in its lifecycle
Admission Date: The date the patient was admitted into the healthcare facility as entered in the 'Enter a new discharge' modal
Discharge Date: The date the patient was discharged from the healthcare facility as entered in the 'Enter a new discharge' modal
From: The name of the discharging healthcare facility as entered in the 'Enter a new discharge' modal and Review Discharge Info screen
Complexity: The level of medical, social, and logistical challenges involved in coordinating a patient's transition, as entered in the 'Enter a new discharge' modal
Actions: Contains Summary, View, and Print TCM Summary functionality
Summary
The 'Summary' button populates the 'Transition Summary' modal that provides additional admission and discharge details related to the selected transition. Users may also use this modal to update the selected TCM's status.
View
The 'View' button leads users to the selected transition's record, where all documentation related to the transition is recorded.
Print TCM Summary
Each transition row will contain a 'Print TCM Summary Report' or a 'Print TCM Summary Draft' option. The button will update based on the TCM status.
If the transition is still in an active state, users can click 'Print TCM Summary Draft' and generate a report that contains all current documentation. This report will contain a draft statement to notify recipients that the information they are viewing may not be complete.
Once the transition is finalized, users can click 'Print TCM Summary Report' and generate the official report.
Adding a New Discharge
The Transitions tab landing screen also contains the function for creating new transition records. When a user clicks the '+ New Discharge' button, they are taken to the 'Enter a new discharge' modal where they can begin entering information related to a patient's current discharge, including:
Patient was discharged and is a candidate for TCM services: This checkbox is used to signify that the patient is eligible for TCM
This field requires a Discharge Date to be saved successfully
This field is required to finalize and bill for the TCM service
Admission Date: The date the patient was admitted into the healthcare facility
This field is required to save the modal and create the new discharge
Admission Reason: The specific medical condition or circumstance that necessitated the patient's admission
This field is required to save the modal and create the new discharge
Anticipated Discharge Date: The projected date the patient is expected to be discharged
If the Discharge Date field is blank, the Anticipated Discharge Date field is required to save the modal and create the new discharge
Discharge Date: The date the patient was discharged from the healthcare facility
This field requires that the 'Patient was discharged and is a candidate for TCM services' checkbox be marked to be saved successfully
This field is required to finalize and bill for the TCM service
Discharged From: The name of the healthcare facility that discharged the patient
This field is required to save the modal and create a new discharge
Complexity of Decision Making: The level of medical, social, and logistical challenges involved in coordinating a patient's transition
This field is required to save the modal and create the new discharge
Click the 'Help me to determine the complexity' link for assistance with determining the transition's level of complexity.
Transition View
Once the 'Enter a new discharge' is saved, the user is automatically directed to the individual transition's record (users can also enter this area by clicking the 'View' button located in the Transitions tab landing screen). Each Transition View contains the following sections:
Patient Information
Patient Name: By clicking the patient name you will be redirected back to the patient view page.
TCM Status Button: This displays the current status of the TCM. When clicked, a user can open the 'Change TCM Status' modal and manually set the TCM to Eligible, Ineligible, or Void/Canceled.
Additional Demographics: The patient's DOB, age, gender, phone number and EHR ID (if applicable)
Patient Flags: All practice flags that the patient is currently associated with
Discharge Overview
This section contains the discharge information entered in the 'Enter a new discharge' modal, including the date of discharge, the discharging location, the reason for the admission, and the transition's complexity. This section will automatically update if/when changes are made.
Communication Overview
This section keeps track of the practice's communications with the patient throughout their transition.
An eligible TCM must include the following:
Initial Communication: A phone call or other valid form of communication that occurs within 2 business days of the patient's official discharge date.
To complete an initial communication, users must document at least two unsuccessful call attempts or one successful call within the 2 business day window
Users can add successful calls and attempts through the '+ Add' link located in the Communication Overview - Initial Communication section or through the Initial Communication screen
Face-to-Face Visit: An in-person or virtual visit that occurs within 7 or 14 calendars of the patient's official discharge date.
If the transition has a moderate complexity, the visit must occur within 14 calendar days
If the transition has a high complexity, the visit must occur within 7 calendar days
Requirements
This section lists the TCM-related screens that require documentation before finalization and billing.
As users progress through the TCM, the To Dos are automatically updated to signify that the requirement was completed.
To access other helpful ThoroughCare articles in the Knowledge Base or to get help from the ThoroughCare Support team members, click the ‘i’ icon in the top right corner of the software next to the username and use the appropriate link!