Evaluating the Effectiveness of a Post-Discharge Care Transition Program in a Resident Ambulatory Practice Ankita Sagar, Tara S Kim, Saima I Chaudhry, Joanne Gottridge North Shore University Hospital, Dept of Internal Medicine, Division of General Internal Medicine Background & Objectives Timely outpatient follow-up post hospital discharge is imperative for safe transitions of care. In Fall 2012, we implemented the Care Transition Program (CTP) at our Patient Center Medical Home (PCMH) for high risk Medicaid patients. The CTP Program is a multidisciplinary team of resident physicians, nurse practitioners, case managers, social workers, health psychologist, case managers, and medical staff. Practice staff alerts residents of hospitalized patients, thus residents make follow-up phone calls to those patients within 48hours of discharge from the hospital. PCMH staff schedules patients for follow-up within 2 to 7 days of discharge depending upon the urgency of visit and complexities of patient's co-morbid conditions. Results Conclusions From January through November, 581 patients from our PCMH were hospitalized. The proportion receiving 48-hour post-discharge follow-up calls rose from 80% (April-June), to 88% (July-September). The proportion of patients seen within 2-days post-discharge decreased from 55% (April-June) to 29% (July-September). However, the proportion seen within 7-days increased from 35% (April-June) to 43% (July-September). Overall, our patient re-admissions decreased from 19% to 9% in the same periods. We achieved a slight increase in post-discharge 48-hour phone calls and a significant increase in 7-day follow-up visits. Importantly, we reduced readmission rates. Percent of Patients Receiving Phone Calls within 48-hours of Discharge 1) Early automated notifications through integrated inpatient and outpatient EMRs at the time of hospital admission or discharge of practice patients. 2) Increasing dedicated resident hours to participate in post-discharge care. 3) Recruiting additional personnel (Nurse Practitioner, Case Managers, and medical secretary) to facilitate outpatient appointments and needed transitions in care. 4) Bi-weekly CTP meetings to risk stratify our Medicaid patients, thus identifying those who may benefit from the CTP initiatives. Percent Re-Admissions within 30 Days 100 50 95 40 90 85 30 80 19 20 70 9 10 65 60 55 0 2nd Quarter 100 3rd Quarter 50 2nd Quarter 3rd Quarter Effectiveness of the CTP Program in 2nd & 3rd Quarter 90 2nd Quarter 3rd Quarter 80 70 P e rc e n ta g e Description of Processes & Methods To evaluate COC effectiveness, we studied the proportion of: 1) readmission rates 2) patients receiving post-discharge phone calls within 48-hours 3) patients scheduling follow-up visits at our ambulatory practice within 2 to 7 days of discharge from the hospital. 75 60 The following CTP facilitated our success: initiatives 50 40 30 . 20 10 0 phone call within 2 days of discharge follow up visit within 2 days of discharge follow up visit within 7 days of discharge Readmission Rates within 30 days About North Shore-LIJ Health System The nation’s second-largest, non-profit, secular healthcare system, North Shore-LIJ delivers world-class clinical care throughout the New York metropolitan area, pioneering research at The Feinstein Institute for Medical Research and a visionary approach to medical education, highlighted by the Hofstra North Shore-LIJ School of Medicine. The winner of the National Quality Forum’s 2010 National Quality Healthcare Award, North Shore-LIJ cares for people at every stage of life at 15 hospitals, long-term care facilities and more than 200 ambulatory care centers throughout the region. North Shore-LIJ's owned hospitals and long-term care facilities house about 5,600 beds, employ more than 10,000 nurses and have affiliations with more than 9,000 physicians. Its workforce of about 42,000 is the largest on Long Island and the ninth-largest in New York City. For more information, go to northshorelij.com.
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