Pilot program introduced to support Medicaid patients discharged from hospital care

Rachel Burt, Watertown Daily Times, N.Y.
·2 min read

Mar. 27—WATERTOWN — A new program is being piloted locally to assist Medicaid patients with the transition from hospital to home.

For some patients, heading home after a stay in the hospital or emergency department can cause them to feel anxious or isolated, and they may not feel confident about which medications to take, providers to follow up with or if other tests are needed.

Without support, their issues may recur, leading to another hospital or emergency department visit. To combat this negative outcome, the pilot program mTCM, which stands for Medicaid Transitional Care Management, will be launched April 1 by North Country Initiative and the North Country Independent Practice Association.

"I am confident that increased care management and timely intervention for our patients will result in positive outcomes and reduced utilization of expensive hospital care through the support and follow up we provide through TCM," Dr. Steven Lyndaker, medical director for NCI and Fort Drum Regional Health Planning Organization and partner at Lowville Medical Associates, said in a prepared statement.

The pilot is roughly nine months long and modeled after a similar, nationally reimbursable service for Medicare patients in which primary care teams review patients' hospital discharge information, check in with the patients within two days after discharge, conduct medication reconciliation and other non-face-to-face services and have face-to-face visits with the patients within one to two weeks after discharges.

The mTCM services are structured similarly to those provided for Medicare patients, with two significant differences: unlike Medicare, the pilot will reimburse for services following an emergency department discharge, and it incorporates a standardized screening to identify patients' social needs.

"Social determinants of health (SDH) are factors that patients may face outside of the traditional healthcare realm, such as housing, transportation, and others," said Amanda Rydberg, RPA-C, Associate Medical Director at River Hospital, in a statement. "Knowing that these types of needs can significantly impact a patient's health and well-being, we are excited to incorporate SDH into the mTCM program. ... This will lend critical insight into the prevalence of social needs and will assist patients through referrals to appropriate SDH services in our community."

Through mTCM, enhanced payments will be made available to North Country Independent Practice Association partners who incorporate SDH screening into their workflows, and who complete all required elements of the mTCM service with patients. The program's outcomes and results, including its benefit to patients and impact on improved quality and reduced cost of care, will be measured to demonstrate the value of incorporating this service into the Managed Medicaid payment structure.