Post-Discharge Care Tip Sheet

Incentives are paid to the linked primary care provider (PCP) on an annual basis, following the end of quarter four. Providers receive full points if they have zero (0) admissions during the measurement period. For additional information, refer to the CBI Technical Specifications.

• Postpartum and healthy newborn care visits are excluded. NICU newborns are included.
• Administrative members at the end of the measurement period or during hospitalization.
• Members discharged and admitted to a Skilled Nursing Facility (SNF) on the same day.
• Dual coverage members.

View the full list of post-discharge care codes in the CBI Technical Specifications.

Data for this measure is collected using claims and provider data submissions via the Data Submission Tool (DST) on the Provider Portal.

The Linked Member Inpatient Admissions report provides a real-time report of your members with inpatient admissions or recent discharges at regional hospitals using eCensus data.

Note: Not all hospitals participate in eCensus.

The quarterly CBI Report in the Provider Portal provides a roster of compliant and non-compliant members, trending graphs, and comparisons to benchmark performance.

If you do not have a Provider Portal account, you can submit a Provider Portal Account Request Form. For questions or concerns regarding the Provider Portal, please contact the Provider Portal Support Specialist at 831-430-5518 or email [email protected].

• Designate a care team member to use the Alliance Provider Portal to create a recall list for patients and attempt to schedule them for their post-discharge appointment within 14 days.
• Designate appointment slots specifically for post-discharge follow-up.
• Incorporate regular reviews of the Linked Member Inpatient Admissions report into front office procedures.
• Members should have a follow-up visit with their PCP after admission, even if the member had a follow-up with a specialist.
• Review discharge instructions with members to ensure they understand their post-discharge care and have assistance at home during their recovery.

• Alliance Cultural and Linguistic Services are available to network providers.
  • Language Assistance Services – request materials at 800-700-3874, ext. 5504.
  • Telephonic Interpreter Services – available to assist in scheduling members.
  • Face-to-Face Interpreter Services – can be requested for the appointment with the member.
  • For information about the Cultural and Linguistic Services Program, call the Alliance Health Education Line at 800-700-3874, ext. 5580 or email us at [email protected].
• Alliance Enhanced Care Management (ECM) and Community Supports.
  • Refer Alliance members through the Alliance Provider Portal, email [email protected], mail or fax, or by phone at 831-430-5512.
  • For Complex Care Management and Care Coordination, call the Care Management team at 800-700-3874 (TTY: Dial 711).
• Alliance Nurse Advice Line to talk to a nurse.
  • 844-971-8907 (TTY: Dial 711).
  • Educate all members to use the Alliance Nurse Advice Line that is available to all Alliance members 24 hours a day, 7 days a week to discuss health concerns to avoid hospital readmissions and preventable emergency visits.
  • Add to your phone-tree and route after-hours calls from Alliance members.
• Alliance Transportation Services for patients with transportation challenges.
  • Non-emergency medical transportation (NEMT), call 800-700-3874, ext. 5640 (TTY: Dial 711).
  • Non-medical transportation (NMT), call 800-700-3874, ext. 5577 (TTY: Dial 711).