Improving care transitions at Harborview Medical Center

1. Improving care transitions at Harborview Medical Center Frederick M. Chen, MD, MPH Chief of Family Medicine Associate Professor, University of Washington

2. The new norm: Discontinuity 1

3. 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

4. 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

5. 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

6. In other words… Results • 23.8 % reduction in 30-day readmission rate • 49.2 % reduction in 30-day ED visits • 18.7 % increase 14-day FMC visit attendance

7. 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

8. 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.

9. AFTER CARE CLINIC: Linking Patients to Primary Care September 2014

10. 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

11. 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

12. 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