Transcript An Inpatient Continuity Service: Do We Have A Role in The

Improving care transitions at
Harborview Medical Center
Frederick M. Chen, MD, MPH
Chief of Family Medicine
Associate Professor, University of Washington
The new norm: Discontinuity
1
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 postdischarge, 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 postdischarge 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
Results
Prior to Continuity Visit Continuity Visit
P-value
2/1/2012 - 8/31/201
9/1/2012 - 1/31/2013
Total readmitted
12.12% (16)
9.23% (6)
0.54
ED visit within 30 d 18.18 % (24)
(for any reason)
9.23 % (6)
0.10
FMC f/up w/in 14 d 40.15% (53)
47.69% (31)
0.31
In other words…
• 23.8 % reduction in 30-day readmission rate
• 49.2 % reduction in 30-day ED visits
• 18.7 % increase 14-day FMC visit attendance
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
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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