Bridging the Transitions of Care

1Karen Scott, MD MPH
New YorkPresbyterianWeill Cornell, New York, NY
2New YorkPresbyterian, New York, NY

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97689

Background:

The immediate post–discharge period is a vulnerable time both for patients and their care providers. Several studies have been published highlighting safety issues identified during the immediate post–discharge period. To address these problems, we designed a program to provide clinically high risk patients with physician post–discharge follow–up at the resident continuity practice “X.”

Purpose:

The Bridge Program is an interdisciplinary approach to (1) improve patient safety in the immediate post–discharge period; (2) improve patient satisfaction with the discharge process; (3) reduce preventable ED visits and readmissions to this hospital within 30 days of discharge.

Description:

Patients >18 years of age who currently have or desire to establish care at “X” were enrolled in the Bridge Program if they were determined by their attending hospitalist to require expedited post–discharge follow–up after treatment of pneumonia or congestive heart failure, or required a focused discharge exam, laboratory testing, and/or medication education. A 9–item survey was submitted by the resident provider following each Bridge visit indicating issues addressed with the patient. ED visits and readmissions within 30–days of discharge from the study hospitalization were calculated through review of each patient’s medical record.

Conclusions:

From April to August 2011, 49 of 108 patients who were enrolled in the Bridge Project attended their appointment (46%). The most common reasons for enrollment were symptom assessment (64%), laboratory testing (29%), and diabetes management (15%). Medication management and advancing clinical care took place during 53% and 47% of the appointments respectively. Medication reconciliation (29%) and reinforcing adherence with discharge medications (30%) were the main medication issues identified. Post–appointment patient surveys were obtained from 49% of patients seen (24/49), all of whom felt that the bridge appointment reinforced their discharge and medication instructions. Ninety–six percent believed that the appointments prevented them from returning to the hospital (23/24). Overall, attending the bridge appointment appeared to reduce the risk of readmission by 44%, although the difference did not reach conventional levels of statistical significance (p=0.15). Although less than half of enrolled patients attended their appointments, important safety issues were identified for over half of the patients who did attend, predominantly medication related problems. The importance of the program has been reaffirmed by the patients themselves who have felt that Bridge appointments were effective in accomplishing their goal, to create a safer transition from the hospital to home.

To cite this abstract:

Maw A, DeJesus C, Ocampo C, Ganz–Lord F, Lee J, Tung J, Tinghitella P, Kaplan S, Bishop T. Bridging the Transitions of Care. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97689. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/bridging-the-transitions-of-care/. Accessed July 17, 2019.

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