Implementation of a Discharge Follow‐Up Clinic for Internal Medicine Patients at an Academic Medical Center

1University of New Mexico, Albuquerque, NM
2University of New Mexico, Albuquerque, NM
3University of New Mexico, Albuquerque, NM

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 175


Two years ago our academic hospitalists observed increasing difficulty in scheduling timely ambulatory follow‐up appointments for patients discharged from teaching and nonteaching hospital services. Several believed that this negatively affected patient care and was contributing 1c preventable hospital re admissions. In addition, some providers delayed discharging patients when medically stable but requiring close outpatient follow‐up after discharge. In response to these concerns, the Hospitalist Section established an Internal Medicine Discharge Follow‐up Clinic.


To develop a follow‐up clinic to assist hospitalists in transitioning care of inpatients back to their primary care providers and to provide another opportunity to reinforce patient education on discharge diagnoses, medications, and follow‐up plan of care.


Patients discharged from the internal medicine inpatient service are scheduled into this clinic when follow‐up within 2 weeks is needed and cannot be scheduled with a primary care provider The attending physician and nurse case manager identify patients who are high‐risk discharges. These patients include (but are not limited to) those patients with poor health literacy, multiple medications, poor socioeconomic status, and recent prior hospitalization or emergency department utilization. The nurse case manager schedules and educates the patient on their discharge clinic follow‐up appointment. The patient is then evaluated by the discharge clinic provider prior To discharge and is given a pamphlet That summarizes the purpose of the discharge clinic, provides the patient with a summary of their appointments, and a checklist for their discharge follow‐up. The discharge clinic supervised by the hospitalists and staffed by a nurse‐practitioner with experience in both inpatient and outpatient medicine. At the time of the discharge clinic appointment, a note is dictated into the chart regarding the follow‐up plan. This note is accessible by Ihe majority of our outpatient providers via access lo our electronic medical record. In the first year of operation there were 449 visits lo the clinic. We are currently evaluating 16 patients per week in clinic, which is about 25% of discharges from the hospitalist services. Patients, residents, hospitalists, and primary care physicians have reported a high level of satisfaction with the discharge follow‐up clinic.


The discharge follow‐up clinic has led to improved provider satisfaction at the time of discharge when timely primary care appointments cannot be facilitated. A current pilot is in progress to assess its impact on length of stay and readmission rates.

Author Disclosure:

I. Krokos, none; T. Osborne, none; J. Pierce, none.

To cite this abstract:

Krokos I, Osborne T, Pierce J. Implementation of a Discharge Follow‐Up Clinic for Internal Medicine Patients at an Academic Medical Center. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 175. Journal of Hospital Medicine. 2010; 5 (suppl 1). Accessed March 30, 2020.

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