Predischarge Provider Visits as a Method of Improving Transitional Care Clinic Visit Rates

Abstract

Background: Transitional care interventions have been associated with reduced 30-day patient readmission, better quality of health care, and lower emergency department visits and health care costs. Local Problem: Transition Services at a major quaternary care center was underutilized by patients who were referred to the program. Methods: A pre-/postimplementation evaluation design was used to evaluate a quality improvement intervention. Intervention: A face-to-face meeting between eligible patients and a Transition Services provider prior to patients being discharged from the hospital was evaluated as a process improvement intervention. The primary outcome was initial appointment attendance at the Transition Services clinic following hospital discharge. Results: There was no statistically significant difference (P = .59) in patients' initial appointment attendance at Transition Services between the preintervention (48.1%) and intervention phases (54.8%). Conclusion: Provider engagement during hospitalization did not increase initial appointment attendance at Transition Services. Other strategies to improve Transition Services attendance rates are needed.

Post-Hospital Availability of Instrumental Support May Influence Patients' Readiness for Discharge

“…Further process changes such as lower nurse to patient ratios (McHugh et al, 2021), postdischarge follow-up such as telephone calls (Schuller et al, 2015), and more comprehensive transitional care interventions (Enderlin et al, 2013) have been evaluated and noted to reduce 30-day readmissions. Efforts to reduce 30-day readmissions have also included evaluating readmissions at specific time periods within the 30-day time frame (Saleh et al, 2020) and facilitating patient follow-up with a primary care provider (Wiest et al, 2019) or receiving a community paramedic visit (James et al, 2020) within the first 7 days after discharge.…”