Post-Discharge Clinic and Transitional Care Programs

Process and Outcomes

The post-discharge clinic (PDC) integrates cross-service line initiatives to provide multimodal transitional care tailored to the needs of the patient as wellas the hospital organization and clinical providers. The PDC aims to 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.

The transitional care interventions provided by the PDC are 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). We work collaboratively with multiple inpatient and outpatient leadership, the office of clinical transformation, quality, case management, pharmacy, finance, community outreach programs, data analytics and other stakeholders 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 who are unable to see their primary care provider (PCP) within seven days of discharge are prioritized to be seen in the PDC. After the patients are discharged from the hospital, they receive a 48-hour transitional post-discharge call. During their PDC visit, patients receive 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.

Access:

The access rate for both new and established patients within a 7-day period is 100%.

Readmissions:

There was a 34% reduction in patients on high-risk readmissions and 33% reduction in ED return visits for patients following at the post-discharge clinic compared to the patients who are not following with us.

Providers