Improving care transitions at Harborview Medical Center

Frederick M. Chen, MD, MPHChief of Family MedicineAssociate Professor, University of Washington

The new norm: Discontinuity1

High risk transitions of care• 20% of Medicare patients are readmitted within 30 days; 34%

within 90 days. Estimated cost upwards of $17 billion annually.4

• 50% of patients have a medication error; up to 85% have discrepancies on inpatient vs. outpatient medication lists on admission or discharge.5,6

• 20% of patients suffer an adverse event in the 3 weeks post-discharge, the majority of which are medication related, followed by procedure related, then abnormal labs.7

• Communication between PCP and hospitalist is poor – direct communication 3-20%. Discharge summary by first post-discharge visit 12-34%.8

Family medicine continuity rounding service• Goals• Provide continuity and connection for patients• Coordinate discharge planning

• Structure• Prioritized rounding on new admissions and impending

discharges on all medical / surgical services• Physician rounder; Clinic nurse designated for transitions• Communicate with primary team and PCP• Reconcile medication and problem lists• Make follow-up appointments within 14 days

Methodology• Data obtained from AMALGA database between 2/1/12 –

2/1/13, including HMC admissions, ED stays, and FMC visits for our patients

• Outcomes• Primary – readmission or ED visits within 30 days for any

diagnosis• Secondary – patient attendance at f/up appointment w/in 14

days

In other words…

Prior to Continuity Visit2/1/2012 - 8/31/201

Continuity Visit9/1/2012 - 1/31/2013

P-value

Total readmitted 12.12% (16) 9.23% (6) 0.54

ED visit within 30 d(for any reason)

18.18 % (24) 9.23 % (6) 0.10

FMC f/up w/in 14 d 40.15% (53) 47.69% (31) 0.31

• 23.8 % reduction in 30-day readmission rate• 49.2 % reduction in 30-day ED visits• 18.7 % increase 14-day FMC visit attendance

Results

Continuity works• Van Walraven, et al, showed an independent association of

follow-up visits with PCP with decrease in urgent admissions.9

• Gill and Mainous demonstrated higher outpatient provider continuity was associated with a lower likelihood of hospitalization, especially from a chronic condition.10

• Misky, et al, found patients lacking timely PCP f/up were 10 times more likely to be readmitted.11

Strategies: Enhanced discharge services

• Incorporating disease specific discharge instructions, discharge telephone monitoring, hospital-run clinics lowered readmission rates 25% ->15%.12

• Hospitalist-run clinic for immediate post-discharge follow-up decreased 30-day risk of death or readmission by 5%.13

• Transitional care model• 8/9 RCTs evaluating readmission showed significant decrease at

30 days, methods centered around enhanced discharge, RN driven care coordination and home visits.14

• 3/9 showed decreased readmission rates at 6-12 months; methods were home visits and telehealth.15,16,17

• These interventions were based out of the hospital, not a PCMH.

AFTER CARE CLINIC: Linking Patients to Primary Care

September 2014

History

• “The safety net for the safety net”• Founded 2008• Goal: bridge unaffiliated

patients from ED/inpatient discharge to primary care

• Grown from few sessions per week to full clinic schedule

Clinic Visit

• Patients referred from ED/Inpatient• Typically appointed with 1-2 weeks • No walk-in visits (ED high utilizer exception)• Reminder call day before• During the visit: – Urgent issues addressed– Follow-up with PCP arranged– Patient leaves with appt date/time & PCP name

• No-show patients are invited back

Future Directions• Ensuring safe transitions• Reducing no-shows in ACC • Reducing no-shows with PCPs

• Streamlining process for PCP referral• Tackling “assigned PCP” • Engaging patients in the process