Improving care transitions at Harborview Medical Center
Frederick M. Chen, MD, MPHChief of Family MedicineAssociate Professor, University of Washington
The new norm: Discontinuity1
High risk transitions of care• 20% of Medicare patients are readmitted within 30 days; 34%
within 90 days. Estimated cost upwards of $17 billion annually.4
• 50% of patients have a medication error; up to 85% have discrepancies on inpatient vs. outpatient medication lists on admission or discharge.5,6
• 20% of patients suffer an adverse event in the 3 weeks post-discharge, the majority of which are medication related, followed by procedure related, then abnormal labs.7
• Communication between PCP and hospitalist is poor – direct communication 3-20%. Discharge summary by first post-discharge visit 12-34%.8
Family medicine continuity rounding service• Goals• Provide continuity and connection for patients• Coordinate discharge planning
• Structure• Prioritized rounding on new admissions and impending
discharges on all medical / surgical services• Physician rounder; Clinic nurse designated for transitions• Communicate with primary team and PCP• Reconcile medication and problem lists• Make follow-up appointments within 14 days
Methodology• Data obtained from AMALGA database between 2/1/12 –
2/1/13, including HMC admissions, ED stays, and FMC visits for our patients
• Outcomes• Primary – readmission or ED visits within 30 days for any
diagnosis• Secondary – patient attendance at f/up appointment w/in 14
days
In other words…
Prior to Continuity Visit2/1/2012 - 8/31/201
Continuity Visit9/1/2012 - 1/31/2013
P-value
Total readmitted 12.12% (16) 9.23% (6) 0.54
ED visit within 30 d(for any reason)
18.18 % (24) 9.23 % (6) 0.10
FMC f/up w/in 14 d 40.15% (53) 47.69% (31) 0.31
• 23.8 % reduction in 30-day readmission rate• 49.2 % reduction in 30-day ED visits• 18.7 % increase 14-day FMC visit attendance
Results
Continuity works• Van Walraven, et al, showed an independent association of
follow-up visits with PCP with decrease in urgent admissions.9
• Gill and Mainous demonstrated higher outpatient provider continuity was associated with a lower likelihood of hospitalization, especially from a chronic condition.10
• Misky, et al, found patients lacking timely PCP f/up were 10 times more likely to be readmitted.11
Strategies: Enhanced discharge services
• Incorporating disease specific discharge instructions, discharge telephone monitoring, hospital-run clinics lowered readmission rates 25% ->15%.12
• Hospitalist-run clinic for immediate post-discharge follow-up decreased 30-day risk of death or readmission by 5%.13
• Transitional care model• 8/9 RCTs evaluating readmission showed significant decrease at
30 days, methods centered around enhanced discharge, RN driven care coordination and home visits.14
• 3/9 showed decreased readmission rates at 6-12 months; methods were home visits and telehealth.15,16,17
• These interventions were based out of the hospital, not a PCMH.
AFTER CARE CLINIC: Linking Patients to Primary Care
September 2014
History
• “The safety net for the safety net”• Founded 2008• Goal: bridge unaffiliated
patients from ED/inpatient discharge to primary care
• Grown from few sessions per week to full clinic schedule
Clinic Visit
• Patients referred from ED/Inpatient• Typically appointed with 1-2 weeks • No walk-in visits (ED high utilizer exception)• Reminder call day before• During the visit: – Urgent issues addressed– Follow-up with PCP arranged– Patient leaves with appt date/time & PCP name
• No-show patients are invited back
Future Directions• Ensuring safe transitions• Reducing no-shows in ACC • Reducing no-shows with PCPs
• Streamlining process for PCP referral• Tackling “assigned PCP” • Engaging patients in the process
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