Virtual Patient-PCP-Hospitalist Care Transition Meeting Before Hospital Discharge

Findings of this quality improvement study highlighted the value of patient-hospitalist-PCP virtual meetings in addressing gaps in information exchange, increasing patient confidence, and improving clinician perceptions of care coordination. These results supported the feasibility and potential of incorporating such interventions as part of routine discharge procedures. The Centers for Medicare & Medicaid Services could consider incorporating a direct interaction component with hospitalists, patients, and PCPs before hospital discharge into the requirements for Transitional Care Management billing or allow current billing codes to be applied in the hospital setting.