Residency Program Initiative to Transform Transitions of Care

From the 2018 HVPAA National Conference

ZAHRAA RABEEAH (Piedmont Athens Regional Medical Center)


Transitions of care often fail to improve health and decrease the cost of care. Competency in the transition of care process is essential, yet it is not necessarily part of the residency curriculum. In our program we designed and implemented a resident led transition of care team.


Implement TOC curriculum, reduce readmission rate and improve show rate in our residency community care clinic


We implemented a multi-component integrated team-based, transition-of-care service intervention and assessed its impact on show rates for TOC visits and 30 days readmission rate.

The 3 components of the intervention starts at the time of discharge by a call to the TOC hotline . The second process is utilizing a call by the TOC lead resident  within 48 hours of discharge which includes medication reconciliation, referrals and social needs. The final step is a face to face TOC visit within 7 to 14 days of discharge with a resident, a pharmacist and a social worker.

We conducted a retrospective chart review of Piedmont Athens Regional Medical Center patients discharged and referred to the TOC residency clinic by calling the TOC hotline prior to discharge

We measured the 30 day readmission rate, and TOC visits show rate. 150 patients were included from December 19, 2017 to March 1, 2018. Data analysis was done using SPSS.


The 30-day readmission rate was 9% for the 150 patients, among the 66 patients who received all components of the intervention the readmission rate decreased to 3%.

The show rate among patients who received the follow up phone call was 90% in comparison to 28% for patients whom we were unable to reach. The general show rate for our clinic for 2017 was 73 %.

The process is ongoing, with monthly data analysis. Future plan includes TOC home visits and mobile clinic to address areas of high utilization of health care.


Resident lead TOC team process is currently built into PAR residency curriculum. Even though we did not find statistical significance in 30 day readmission rate the high value care provided reduces the cost of health care with substantial savings to the larger health care institution as 40% of the patients discharge don’t have access to primary care service.This method could be implemented in other residency programs to emphasize the culture of safe transitions.

Implications for the Patient

The initiative led to building a TOC experience for internal medicine residents. It created the process, provided easy access though the hotline to ensure proper transitioning from the inpatient to the outpatient setting .And more importantly it increased our TOC visit show rate.

What are academic medical centers across the country doing to improve healthcare value?

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