An Enhanced Care Transition Program

From the 2023 HVPA National Conference

Christina Muggeo BA (NYU Langone Health), Katie Tobin MHA, Christine Truiano BA, Adriana Quinones-Camacho MD, Steve Chatfield MBA, Kevin P. Eaton MD

The transition of care from hospital to home is a critical period for optimizing health outcomes. One important aspect to a safe transition is appropriate and timely post-discharge follow-up. Large academic medical centers often have complex and differing methods for ordering referrals as well as a lack of tracking capabilities for patients’ transitions between the two settings. Ensuring timely access of care after discharge can significantly improve patients’ quality of life, health outcomes, and hospital experience.

We aimed to implement a standardized referral process where outpatient referrals ordered by inpatient providers were scheduled prior to (or shortly after) patients were discharged. We started with piloting the workflow on a 32-bed house staff run general medicine unit in a large academic hospital in November 2021. We then expanded the workflow to all 7 inpatient general medicine services in April 2022. Educational materials were created for care teams and presented at hospital-wide forums. We tracked the number of referrals placed, scheduled, and completed. We measured the process metrics of number of referrals placed, scheduled, and completed. We hypothesized that patient satisfaction would improve with the addition of this workflow.

No baseline data was available given the limited tracking capabilities prior to the intervention. However, comparison from pilot to expansion timeframes showed a 64% increase (25% in Nov. 2021 to 41% in Nov. 2022) in the percentage of discharges with an ordered referral. There was a 70% increase in the percentage of discharges with a scheduled referral and a 33% increase in those with a completed referral. We had a 15% increase in completed appointments within 14 days post-expansion. Our HCAHPS top box scores for Willingness to Recommend and Overall Rating was higher for those receiving our assistance in scheduling follow-up appointments after discharge.

Enhanced communication, continued education, and better data transparency have led to improved transitions of care and higher quality of care for patients. Additionally, it has allowed for the identification of further process improvements both in the discharge planning and scheduling processes.

By utilizing data-driven decision making throughout the care continuum, it will allow every step of the patients’ care pathway to be comprehensive and reliable. Discussions are currently underway to determine how to enhance reporting, standardize the process across all facilities, and expand to other departments.

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