Transitions of care for high-risk, frequently hospitalized adults are complex, costly, and vulnerable to errors and poor health outcomes.(1) Hospital discharge is a particularly unstable time in a patient’s care; nearly 40% of patients have a test or diagnosis work-up pending at the time of discharge.(2) More than 20% of hospitalized adult patients in the United States experience adverse events within three weeks of discharge, with adverse drug events being the most common.(3) Communication breakdowns, information lapses, and unintended consequences often result in medication nonadherence, decreased disease management, limited follow-up on test results or treatment plans, and missed post-discharge follow-up visits(4,5)—all of which can lead to preventable readmissions or emergency department return visits.(6) Sixty-five percent of patients have adverse events that could be prevented with improved post-discharge and transitional care.(2,3,7) Adverse event prevention is so important that the National Academy of Medicine identified care transitions as a national priority goal for improving the quality, safety, and value of healthcare(2); care transitions are now a target of The Joint Commission National Patient Safety Goals.(8)
Healthcare systems across the country have implemented a variety of standardized care coordination strategies to support care transitions between hospital, ambulatory, and home settings.(9-18) However, care transition programs often are not tailored to the individual patient and are not consistently optimized or delivered appropriately across settings. Close ambulatory follow-up after hospital discharge provides a critical opportunity to reduce medication errors, offer education, and provide ongoing support to reduce preventable readmissions.(19,20) Moreover, there is still a gap in our knowledge about how patient-centered variables, such as perceptions of in-hospital or post-discharge care, satisfaction with providers, and social support at home, among others, may impact medication adherence or contribute to readmissions.(21-25) Multilevel interventions can become complex and increasingly vulnerable to errors and adverse events.(26,27) This continues to be an issue as ambulatory care coordination failure rates in the United States (9.8%) are among the highest across high-income countries.(28) To decrease future readmissions and other adverse events, programs must be specific to the needs of the patient, hospital, and even clinicians providing post-discharge care.
The post-discharge clinic (PDC) in this academic center integrates cross-service line initiatives to provide multimodal transitional care tailored to the needs of the patient as well as the hospital organization and clinical providers. The PDC decreases patients’ length of stay during hospitalization, offers early identification of disease complications or adverse events to prevent future readmissions, provides critical patient-centered education, and supports post-discharge care until patients are able to follow up with primary care.
METHODS
Innovation
The transitional care interventions provided by the PDC were strategically designed, implemented, and iteratively evaluated, accounting for organizational goals, assessment of inpatient care processes, risk of readmission, inpatient and primary care service benchmarks, inpatient and outpatient scheduling processes, financial limitations, internal and external stakeholder input, and the diverse population seeking care at the University Medical Center (UMC). PDC leaders in the hospital medicine section worked collaboratively with outpatient leadership and the Office of Clinical Transformation to implement transitional care interventions that begin during a patient’s hospitalization through care coordination with inpatient providers, residents, case managers, and patient navigators. The EPIC templates created allowed patient navigator coordinators to schedule both in-network and out-of-network patients directly into the PDC for post-discharge visits. Patients discharged from acute care at the UMC were stratified by their risk of readmission. Patients with a higher risk of readmission who were unable to see their primary care provider (PCP) within seven days of discharge were prioritized to be seen in the PDC. Those with a lower risk of readmission were scheduled in the PDC within 14 days of discharge if they were unable to see their PCP. After the patients were discharged from the hospital, they received a 48-hour transitional post-discharge call. During their PDC visit, patients received comprehensive disease and medication education, medication reconciliation, opportunities to discuss any adverse events, evaluation of their social support, and referral to other services.
Patients are provided with a direct phone number for their PDC provider and are followed up as needed until they can be seen by their PCP. PDC providers are instructed to encourage and support patients’ involvement and follow up with their external primary care providers. The PDC provides primary care provider communication, which emphasizes points of care pending during the patients’ transition, and a direct number to contact PDC providers for questions about hospitalization and transitional care. These innovative transitional care processes, along with the strong partnerships that have been built with multidisciplinary leadership and stakeholders, communication with referred providers and primary care, and emphasis on patient support, are the foundations of our integrated transitional care model and differentiate us from other institutions.
In addition to the innovation of the PDC itself, our proposal is novel in that it aims to gather critical patient-centered data that often are overlooked. Patient perspectives, satisfaction, and social support often are not well studied, nor are they considered important factors influencing health outcomes. Our research will result in a comprehensive data set regarding patient perceptions of their health and care and will analyze these data to look for associations with adverse outcomes after hospital discharge. The results of this study will provide further insight into which variables impact post-discharge outcomes and how both in-hospital and transitional care practices can be improved to reduce adverse events and preventable readmissions.
Institutional Challenge
The UMC operates two hospitals: a larger new hospital and another one on the same campus. The UMC rates of readmissions and length of stay showed diverse scorecard variabilities across services and departments. Access refers to the organization’s ability to schedule transitional appointments within 14 days post-discharge. The UMC showed a larger variability in meeting this target. Post-discharge care appointments are necessary to identify adverse events, provide patient education and medication reconciliation to improve medical adherence, and monitor patients at a high risk of readmission. To overcome these challenges, we developed and implemented a virtual PDC to evaluate the impact of our transitional strategy on teaching and nonteaching general medicine services.
Operational Strategy and Challenges
The PDC aims to identify early adverse events, patient education, and medical adherence and improve access to primary care and specialties. As a new clinic, the PDC faced budget, location capacity, sponsorship, staffing, and provider recruitment challenges. These challenges were strategically addressed through collaboration and support from the hospitalist section and intuitional stakeholders such as hospital administration, ambulatory leadership, population health, the department of finance, and case management. A cost and capacity analysis was conducted to justify operational requests for the PDC. This resulted in the approval of a physical clinical space as well as clinical and nonclinical support, which included medical assistants (MAs), patient navigation coordinators (PNCs), data analytics, administrative management, marketing and communication, and patient relations. The cost analysis also accounted for physician effort, which resulted in the recruitment and compensation of the PDC physicians. Additionally, the finance department provides support for navigating out-of-network patients and charity care. We map and lean the processes and simplify our operations for providers, staff, and patients.
Post-Discharge Clinic Flow Mapping and Implementation
In making the PDC operational, three workflows were developed:
Patient identification: Eligibility criteria included patients who require ancillary test follow-up or new tests before an appointment; need reevaluation for response to therapy; require maintenance of pain control; need additional education, including family members; need increased confidence and ability to adhere to the prescribed treatment; do not meet inpatient criteria but feel uncomfortable being discharged; and do not have PCP follow-up within 2 weeks post-discharge. Although we established initial patient criteria, we also opened the PDC to providers who wanted to make a referral.
Scheduling: Patient navigation coordinators reached out to eligible patients to schedule a PDC visit within 14 days of discharge. A novel self-scheduling system allows patient navigation coordinators to schedule patients directly in their provider schedules.
Clinic flow: Prior to the clinic visit, patients received a follow-up call from a population health nurse within 48 hours of discharge. During the visit, PDC physicians provided care, including medication reconciliation and adherence, patient and family education, and communication with the patient’s PCP.
Workflow
Almost all the PDC visits were offered. For virtual visits, communication occurred via MyChart and Doximity. As the clinic gained traction at the UMC, the number of sessions offered per week expanded from one to three. The number of hospitalists actively seeing patients in the PDC also expanded, from one to five providers.
For out-of-network patients, the PDC operations team partnered with the finance department to determine the standard workflow that would continue to provide the highest quality of care, while minimizing the financial burden to both the patient and the organization. The financial workflow served as a tool to identify which out-of-network patients would require leadership approval before completing their PDC visits.
Out-of-network requests were submitted to UMC leadership using the RedCap form. Along with patient information, a justification for the one-time out-of-network exception was submitted. Justification for the exception included patient safety and quality of care, reduction of length of stay, reduction of mortality, and reduction of the risk for 30-day readmission. Additionally, by partnering with the Population Health team and leveraging video visits, the PDC was able to participate in transitional care management (TCM), and, thus, submit bills using TCM codes. TCM is a Medicare-sponsored program aimed at reducing preventable readmissions and medical errors post-discharge, and recognizes the additional care efforts required to support patients after discharge. Three requirements must be met to qualify for TCM: 1) complexity of the patient; 2) population health nurse consultation with the patient within 48 hours of discharge; and 3) PCP visit scheduled within 14 days of discharge.
Marketing and Expansion
Initial internal marketing efforts targeted the BSD hospitalist section and UMC leadership. PowerPoint presentations were conducted to garner leadership and physician buy-in for the PDC and to advertise the clinic’s post-discharge services, resulting in a positive impact on patient outcomes. These efforts were later expanded to general medicine teaching services, select specialty services within the department of medicine, and the short-stay unit. In addition to marketing efforts, educational materials were provided to the department of case management and the short-stay unit.
RESULTS
Tableau Scorecard and Key Metrics Development
A Tableau dashboard(29) was created in partnership with the UMC’s data and analytics team to track key metrics and measure the performance of the PDC. Key metrics tracked on the dashboard include patient lead-time, case mix index, observed-expected (O-E) length of stay, readmissions, and visit volume (i.e., scheduled, completed, canceled, no-show appointments).
Results and Discussion
Between December 2021 and November 2023, 503 patients completed PDC visits. Patients’ readmission and ED return rates were stratified by the Risk of Readmission Score and were compared between patients attending the PDC and those not attending the PDC; data were collected by the data analytics department. Our results demonstrated the following:
PDC patients: readmission rate for patients at high risk of readmission within 30 days post-hospitalization: 23% (Table 1).
No PDC visit: readmission rate for patients at high risk of readmission within 30 days post-hospitalization: 36% (Table 1).
PDC patients: ED return rate for patients at high risk of readmission within 30 days post-hospitalization: 35% (Table 2).
No PDC visit: ED return rate for patients at high risk of readmission within 30 days post-hospitalization: 50% (Table 2).
There was no difference in the observed expected length of stay between patients who did and did not see the PDC. In addition, it is difficult to capture bed-day savings, but based on the patient population seen in the PDC, we can assume that a significant number of patients were discharged to follow up at the PDC to enhance the UMC’s initiatives to decrease length of stay.
Lead-time data show that patients are 2.25 times more likely to complete an ambulatory visit 14 days post-discharge compared with the broader UMC patient population. This indicates that the PDC offers a significant capacity to capture patients at a critical time in their transitional care to primary care and specialty services, with 90% of patients completing a PDC visit within 14 days post-discharge (Figure 1).
From a financial perspective, shifting care from the inpatient to outpatient setting greatly reduces the inpatient care cost by DRG bundles, decreasing the financial burden on the organization, and improving inpatient capacity. In addition to cost reductions, there are financial incentives attached to TCM code billing, which reward providers who are committed to delivering transitional care.
The PDC has taken an approach that leads toward continuous operational improvements. Through collaboration with internal stakeholders and leadership support, the PDC overcame its initial challenges and evolved into an exemplary model of innovative and cost-effective patient care. To sustain this momentum, the PDC has committed to data-driven decision-making and the progression of transitional care at the UMC.
CONCLUSION
Leadership, a well-structured strategic plan, and networking with internal stakeholders for resource utilization are critical for implementing transitional care interventions with limited budgets. Providing transitional timely access for patient education, identification of adverse events, medication reconciliation and coordination of care, and transitional care interventions through a post-discharge clinic can improve medical adherence and patient engagement in their health, leading to a reduction in the risk of readmissions and ED return visits, decrease in the lead time for primary care services, and improve the safety and quality of care delivered. Sicker patients can be identified and referred for early readmissions, saving bed days that would otherwise be utilized at higher-intensity services. Limitations of the study include the small sample size.
References
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-841. https://doi.org/10.1001/jama.297.8.831
Agency for Healthcare Research and Quality. Readmissions and adverse events after discharge. September 7, 2019. Available at: https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge .
Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.
Boult C, Leff B, Boyd CM, et al. A matched-pair cluster-randomized trial of guided care for high-risk older patients. J Gen Intern Med. 2013;28:612-621. https://doi.org/10.1007/s11606-012-2287-y
Clarke JL, Bourn S, Skoufalos A, Beck EH, Castillo DJ. An innovative approach to health care delivery for patients with chronic conditions. Popul Health Manag. 2017;20(1):23-30. https://doi.org/10.1089/pop.2016.0076
Oduyebo I, Lehmann CU, Pollack CE, et al. Association of self-reported hospital discharge handoffs with 30-day readmissions. JAMA Intern Med. 2013;173:624-629. https://doi.org/10.1001/jamainternmed.2013.3746
Long P, Abrams M, Anderson G, et al. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press, 2017. https://doi.org/10.17226/27115
The Joint Commission Hospital 2020 National Patient Safety Goals. www.jointcommission.org/standards/national-patient-safety-goals/hospital-2020-national-patient- safety-goals. Accessed October 26, 2020.
Advancing successful care transitions to improve outcomes. Society of Hospital Medicine. www.hospitalmedicine.org/clinical-topics/care-transitions/ . Accessed October 26, 2020.
Coffey C, Greenwald J, Budnitz T, Williams MV. Project BOOST Implementation Guide. Society of Hospital Medicine. https://www.hospitalmedicine.org/globalassets/professional-development/professional-dev-pdf/boost-guide-second-edition.pdf . Accessed October 26, 2020.
Geriatric Nursing Protocols and Symptoms. The Hartford Institute for Geriatric Nursing Transitional Care. https://consultgeri.org/geriatric-topics/transitional-care . Published January 8, 2016. Accessed October 26, 2020.
The Care Transitions Program. https://caretransitions.org/ . Accessed October 26, 2020.
Improving Chronic Illness Care. https://www.act-center.org/application/files/1616/3511/6445/Model_Chronic_Care.pdf . Accessed October 26, 1, 2020.
Project RED (Re-Engineered Discharge). www.bu.edu/fammed/projectred/ . Accessed October 26, 2020.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775. https://doi.org/10.1001/jama.288.14.1775
Berry LL, Rock BL, Smith Houskamp B, Brueggeman J, Tucker L. Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clin Proc. 2013;88:184-194. https://doi.org/10.1016/j.mayocp.2012.10.016
Hysong SJ, Che X, Weaver SJ, Petersen LA. Study protocol: identifying and delivering point-of-care information to improve care coordination. Implement Sci. 2015;10:145. https://doi.org/10.1186/s13012-015-0335-9
Jeffs L, Kitto S, Merkley J, Lyons RF, Bell CM. Safety threats and opportunities to improve interfacility care transitions: insights from patients and family members. Patient Prefer Adherence. 2012;6:711-718. https://doi.org/10.2147/PPA.S36797
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314-323. https://doi.org/10.1002/jhm.228
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646-651. https://doi.org/10.1046/j.1525-1497.2003.20722.x
Felix HC, Seaberg B, Bursac Z, Thostenson J, Stewart MK. Why do patients keep coming back? Results of a readmitted patient survey. Soc Work Health Care. 2015;54(1):1-15. https://doi.org/10.1080/00981389.2014.966881
Stein J, Ossman P, Viera A, et al. Was this readmission preventable? Qualitative study of patient and provider perceptions of readmissions. South Med J. 2016;109:383-389. https://doi.org/10.14423/SMJ.0000000000000465
Strunin L, Stone M, Jack B. Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization? J Hosp Med. 2007;2:297-304. https://doi.org/10.1002/jhm.206
Jeffs L, Dhalla I, Cardoso R, Bell CM. The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable? J Interprof Care. 2014;28:507-512.. https://doi.org/10.3109/13561820.2014.923988
Carter J, Ward C, Thorndike A, Donelan K, Wexler DJ. Social factors and patient perceptions associated with preventable hospital readmissions. J Patient Exp. 2020;7(1):19-26. https://doi.org/10.1177/2374373518825143
Jeffs L, Kitto S, Merkley J, Lyons RF, Bell CM. Safety threats and opportunities to improve interfacility care transitions: insights from patients and family members. Patient Prefer Adherence. 2012;6:711-718. https://doi.org/10.2147/PPA.S36797
Agency for Healthcare Research and Quality Care Coordination Measures Atlas Update: Chapter 2. What is Care Coordination? www.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html . Accessed October 26, 2020.
Penm J, MacKinnon NJ, Strakowski SM, Ying J, Doty MM. Minding the gap: factors associated with primary care coordination of adults in 11 countries. Ann Fam Med. 2017;15(2):113-119. https://doi.org/10.1370/afm.2028
University of Chicago Data Analytics located at Tableaus and Ambulatory dashboard. https://edm.uchospitals.edu/#/site/main/views/PDCAnalysis/EDReturnsandReadmissionsbyRiskGroup?:iid=1 .