See You Later! Using Telemedicine to Improve Care Transitions

From the 2021 HVPAA National Conference

Kevin P. Eaton (NYU School of Medicine), Jack Amory (NYU Langone Health), Anjana Sreedhar, Eric Goldberg, Brian Bosworth


Transition of care from hospital to home is a critical period for optimizing patient safety and health outcomes. The increasing utilization of telemedicine across health systems provides an additional resource for improving care transitions. Few studies have evaluated the feasibility of utilizing physician-led post-discharge video calls in additional to regularly scheduled outpatient follow-up.


To develop a workflow for post-discharge video calls to be conducted by an inpatient general medicine team through an EMR-based telehealth platform.


This pilot program was implemented on a housestaff-run 32-bed general medicine unit in November 2020. Patients discharged home were scheduled for a video visit follow-up with the same inpatient physician that cared for them during their hospitalization.

These visits occurred within 2 business days of discharge and did not replace the normally scheduled primary care provider visit within 7-10 days. The encounters were conducted by the senior resident together with the hospitalist attending in the afternoon on three designated days per week.

Our providers used an EPIC-integrated telehealth platform to connect virtually with patients through the MyChart portal. Patients with telecapable devices were enrolled in MyChart prior to scheduling. Patients without telecapable devices were scheduled for telephone calls.

The key components of a discharge follow-up visit were addressed including symptom management, medication reconciliation, and confirmation of home services. An escalation workflow for non-clinical issues was developed with the assistance of care management, social work, pharmacy, and the patient experience team.


Over 200 patients have been scheduled for discharge virtual follow-up visits with an overall completion rate of 52%. Additionally, over 50% of completed encounters were with patients considered high risk for readmission at time of discharge. For the month of April, 29% of visits identified issues with symptom management or medication reconciliation.


Our workflow for physician-led discharge virtual follow-up visits is feasible even on a busy housestaff-run general medicine unit in a large academic medical center. Our next steps will include expansion to additional inpatient units with a focus on assessing efficacy by measuring the effect on readmission rate and HCAHPS scores for Care Transitions and Discharge Information.

Clinical Implications

Post-discharge follow-up calls conducted by nurses or care management have shown conflicting results on the reduction of readmission rate and ED utilization. Few studies have evaluated the effect of virtual telehealth and physician continuity on these important metrics for patient outcomes and hospital reimbursement. Our platform is feasible and can help to address these unanswered questions.

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