Northern Care Trust runs Transitional Care Management for roughly 6,000 discharges per year across nine clinics. The TCM 7-day and 14-day codes (99495, 99496) require both an interactive contact within 2 business days of discharge and a face-to-face visit within the window, and Northern was missing the 48-hour contact more often than its leadership was comfortable with.
The challenge
Discharge summaries arrived from a dozen hospital systems on no fixed schedule. By the time the right care manager learned a patient had been discharged, the 48-hour clock was sometimes more than halfway expired. There was no shared view of which discharges were still inside the window, which were about to breach, and which had already missed.
What changed on 31M
Northern routed every discharge into a single TCM intake queue, with SLA timers that count down per discharge and escalation rules that surface at-risk windows to a supervisor before they breach.
- One TCM intake queue fed by all upstream hospital feeds.
- Per-discharge countdown timers with color states (green / amber / red).
- An escalation rule that pages a supervisor when a discharge crosses 36 hours without an attempted contact.
- A documentation template that captures the contact method, talk-through topics, and medication reconciliation in one form.
Results
Northern hit 100% SLA compliance on the 2-business-day contact across the entire footprint in the first full quarter on 31M. Equally important: the supervisor's escalation queue, which started at roughly 40 items a week, dropped to single digits within six weeks. The team self-corrected once they could see the SLA in real time instead of in a retrospective report.