Continuous Care: Implementation of a Virtual and In-Person Transitional Care Management (TCM) Clinic by Internal Medicine Residents

From the 2021 HVPAA National Conference

Patrick Li (NYU Langone Health), Vickie Kassapidis, Ramiro Jervis, Rachael Hayes, Daniel Sartori, Marwa Moussa


The time between hospital discharge and primary care follow-up has historically been a vulnerable period for patients. The COVID-19 pandemic has exacerbated this transitional period, as patients have been forgoing their routine healthcare visits, losing touch with their primary care providers (PCPs), and not having a point of contact for their health needs after they leave the hospital. We launched a new resident-led virtual and in-person post-discharge clinic at an urban academic hospital connected in order to address the increasing need for follow-up care after hospital discharge.


To introduce a new type of visit to improve continuity of care for patients recently discharged from acute care. A secondary objective was to apply data from TCM visits to identify areas for improvement in the hospital discharge process.


Patients admitted to the hospital who did not have a PCP or could not schedule a PCP visit within 10 days after being discharged were given the option of either an in-person or video TCM visit with an internal medicine resident. Each visit consisted of a templated set of questions, including whether medications were reconciled, and if follow-up appointments were scheduled.


Between October and December 2020, there were a total of 79 scheduled TCM visits (28 virtual visits and 51 in-person visits) and 51 (67%) completed visits. For the virtual visits, there was a 86% (24/28) completion rate. For in-person visits, there was a 53% (27/51) completion rate. In 31% (16/51) of the visits, subspecialty appointments were not scheduled at the time of discharge. In 12% (6/51) of the visits, there was a discrepancy with the medications patients were discharged with, with 50% (3/6) due to mis-prescribed antihyperglycemic agents.


The increased completion rate of virtual visits as compared to in-person visits (86% vs. 57%, respectively) suggests virtual visits may be a more convenient and preferable mode of follow-up for patients after hospital discharge. This increased utilization of telemedicine in a primarily Medicaid/uninsured population that has traditionally faced greater barriers to technology adoption is notable. This pilot also shows how TCM visit data can offer insights about the hospital discharge process that would otherwise go unnoticed. The data on discrepancies in medications reveals antihyperglycemic medication reconciliation may be a potential area of focus to improve the hospital discharge process. More data is needed to determine the effectiveness of this resident-led TCM initiative, including its effects on hospital readmission rates.

Clinical Implications

The preliminary data suggests that resident-led TCM visits, especially virtual visits, may effectively bridge gaps in care from the time patients leave the hospital until they establish more permanent care. These visits have also helped capture data on areas for improvement in the discharge process.

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