Discharge Coordination and Transitions in Care: Utilization of Patient Calls and Prescheduled Primary Care Appointments to Promote a Seamless Transition in Care

1HCA Physician Services, Brentwood, TN
2Centerpoint Medical Center, Independence, MO

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

Abstract number: 97712

Background:

A coordinated, standardized hospital discharge process helps to ensure a safe and adequate transition in care. All patients need to clearly understand discharge instructions, have access to discharge medications and have a plan for follow–up care prior to leaving the Hospital.

Purpose:

To implement a discharge process that incorporates communication and coordination of care with the patient’s Primary Care provider with follow–up communication with the patient to identify and intervene appropriately with post–discharge issues.

Description:

Our team developed a multidisciplinary discharge process to improve the patient’s post–hospitalization care transition by focusing on a) communication and coordination of care with the patient’s Primary Care provider and b)direct communication with the discharged patient. For patients admitted to the Hospitalist service that lack a Primary Care provider, a list of Primary Care practices accepting new patients is placed at each Nursing station for use by the Hospitalist and Unit Staff. The patient and Hospitalist work to identify an accepting Primary Care provider. An appointment is made with the receiving Primary Care provider before the patient is discharged, and the appointment is included with the patient’s discharge instructions. The Hospitalist Coordinator faxes a discharge summary and other pertinent information to the accepting Primary Care provider. Forty–eight hours after discharge each patient receives a phone call from a Nurse, using a standardized script to elicit understanding of discharge instructions, verification that discharge medications have been obtained, current symptoms or concerns, pain level, and overall satisfaction with the Hospital experience. If the patient has not obtained discharge prescriptions due to financial reasons, the Case Management department is notified electronically so that financial assistance can be provided. For patients that are unfunded or uninsured, discharge instructions include information on community resources such as discount pharmacy programs and community–based primary care clinics. Additionally, each patient discharged from the Hospitalist service receives a thank you card that is mailed after discharge.

Conclusions:

This discharge process has improved transition in care by ensuring patients leave the hospital with a follow–up appointment with a Primary Care provider, and the follow–up phone call allows for early intervention with post–discharge issues. Readmssion rates have decreased by 1% and HCAHPS patient satisfaction scores in the physician communication category have increased from 70% to 75% since implementation of this process.

To cite this abstract:

Holbrook R, Tahiliani V. Discharge Coordination and Transitions in Care: Utilization of Patient Calls and Prescheduled Primary Care Appointments to Promote a Seamless Transition in Care. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97712. https://www.shmabstracts.com/abstract/discharge-coordination-and-transitions-in-care-utilization-of-patient-calls-and-prescheduled-primary-care-appointments-to-promote-a-seamless-transition-in-care/. Accessed December 10, 2018.

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