Bridging the gaps in transition of care in a residency practice

From the 2018 HVPAA National Conference

Kshitij Thakur (Crozer-Chester Medical Center)


Transition of care from inpatient to outpatient setting is a critical time for patients. Studies have shown that approximately 49% of patients experience at least one medical error during this time.  Transition of care management (TCM) visits become even more difficult in resident run practices due to limited outpatient hours.


It has also been found that education regarding TCM visits is lacking in most residency curricula. This gap was identified at our community hospital based residency program with a 14 day post hospital discharge follow up rate of 29.4%. A quality improvement project was initiated at our residency program in June 2015 with a clear aim to improve our TCM visit rate by 10% in one year.


We implemented several key initiatives to improve our inpatient-to-outpatient transition of care. We educated the residents about the importance of transition of care via noon conference lectures. . Residents were instructed to notify the outpatient office at the time of discharge to ensure proper communication. This notification was done via an EMR update with a brief hospital course and discharge plan. . Office was staffed with a nurse care manager who contacted newly discharged patients within two working days of hospital discharge and reviewed the discharge instruction and medications. A follow up appointment was also made at the time of this follow up call. Specific TCM slots were reserved for these visits in the resident schedules to ensure timely follow up.


We tracked our TCM visit rates in six month increments for 18 months. Baseline 14 day hospital discharge follow-up prior to intervention was 29.4%, within 6 months of these interventions our rate improved to 46.9%. At 12 months this number further improved to 47.6% and at 18 months a significant increase to 64.25%


Development of a transition of care intervention, improved post hospital follow-up. This intervention incorporated a multidisciplinary approach which included communication between the inpatient medical service and the outpatient practice along with a nurse care manager who facilitated the transition of care. This model can be used to structure programs in similar resident run practices across the country to improve post hospital follow-up

Implications for the Patient

Most of the studies in the past have focused on efforts to reduce hospital admissions though inpatient discharge planning. While no single intervention has significant effect on readmission rate, bundled intervention involving post discharge follow up, and patient centered discharge instructions may decrease readmission rate.

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