Understanding and Improving UCLA’s Transitions of Care Between the Inpatient and Outpatient Setting

From the 2018 HVPAA National Conference

Neha Agarwal (UCLA Ronald Reagan), Jamie Agarwal (UCLA Ronald Reagan), Meghan Neckrebecki (UCLA Ronald Reagan), Ashley Busuttil (UCLA Ronald Reagan), Sun Yoo (UCLA Ronald Reagan), Erin Dowling (UCLA Ronald Reagan)


The transition between inpatient care and re-entry back home with outpatient supervision is a vulnerable time period for patients. Understanding the handoff weaknesses in a busy tertiary care academic hospital is crucial to preventing readmissions, avoiding emergency room visits, ensuring access to outpatient services, and improving patient satisfaction and safety.


While various models of inpatient to outpatient transitions of care have been discussed in the literature, no model has consistently outperformed the others. This project aims to understand the current transitions of care within the UCLA Department of Medicine, and apply best practices to this busy, academic, tertiary medical center to reduce readmissions and improve patient safety.


A literature review including the key terms “transitions of care” was performed. Based on this search, two surveys were generated and distributed to identify perspectives on the current transitions of care and areas for improvement; one to UCLA internal medicine hospitalists, one to UCLA attending and resident PCP’s. A chart review of patients not evaluated by an UCLA-PCP within 10 days from discharge was performed. When applicable, patients were called to further elucidate their reasons for not presenting to a post-discharge follow-up appointment. Based on an analysis of this data, a standardized discharge summary template, smart set, and billing protocol are being implemented for the inpatient discharge and the outpatient post-hospital discharge settings.


Charts from 100 patients who were discharged from the UCLA inpatient setting but missed their PCP post-hospital discharge appointment within 10 days during the months of October-December 2017 were reviewed. Common reasons for missed appointments included: 1) the appointment was not scheduled within 2 weeks from discharge (20.3%), 2) readmission (18.5%), 3) patient was seen outside the UCLA system (13%), 4) patient cancelled because they felt well (11%), 5) scheduling problems (9.3%), 6) not scheduled with preferred physician (5.5%), and 7) other (22.4%). To date, 109 PCP’s (54.2% residents) across the various Southern California UCLA clinics, and 57 hospitalists have completed surveys. PCP’s have identified the discharge summary as the preferred method of handoff (92% PCP’s), with a message through the electronic system being the next best method (48%). This is in contrast to hospitalists who believed the 2nd best method for handoffs was personal emails. PCP’s also reflected that discharge summaries are often not available or are commonly missing crucial components such as management scripts (“if-then statements) and home health details. While both inpatient and outpatient providers identify discharge medication reconciliation as important, both agree this is not documented clearly within handoffs. Investigators are currently creating a standardized discharge summary template, and a post-hospitalization discharge follow-up template with accompanying smart-sets for this ongoing study.


A succinct, standardized discharge summary that lists discharge diagnoses, medication changes, home health orders, durable medical equipment orders, labs and imaging requiring follow-up, and management “if-then” scripts can streamline the post-hospital discharge appointment and provide a more effective inpatient to outpatient handoff. A standardized template for the post-hospital discharge visit accompanied by billing smart sets can provide the PCP with more time to address a patient’s health literacy, short-term management, and long-term goals of care.

Implications for the Patient

Identifying the optimal transition of care between the inpatient to outpatient setting in a tertiary care academic referral center can improve patient satisfaction, reduce iatrogenic complications, decrease readmissions, and decrease overalls cost of care.

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