"Inpatient teams face important limitations in ensuring safe transitions to ambulatory settings," the report continues. "Given the great variability of inpatient and ambulatory care team resources and capabilities, there can be no 'one-size fits all' model for safe care transitions; but certain tasks during care transitions are probably best carried out by members of the ambulatory rather than the inpatient care team, since the ambulatory practice will be responsible for providing ongoing care to the patient in the ambulatory setting."
The five responsibilities outlined in the report include:
The report was issued this month shortly after Medicare announced that it will accept the newly created Current Procedural Terminology codes for care coordination to pay physicians for the management of patients who have recently been discharged from a hospital or skilled nursing facility, the AMA said.
The AMA's CPT Editorial Panel built the codes to catalog care management services, including time spent talking about a care plan, connecting patients to community services, transitioning them from inpatient settings and preventing readmissions.