Background: Virtual care is becoming a fully realized modality of providing patient care (1, 2). In hospital medicine, the transition of care from inpatient to outpatient can be challenging to carry out efficiently and effectively while mitigating any preventable harm that may arise prior to a scheduled follow-up appointment with a primary care physician (PCP). Validated scoring tools such as the LACE (Length of stay, Acuity of admission, Co-morbidities and Emergency room visits) index are used to identify patients at higher risk of readmission (3). Identifying higher risk patients may allow healthcare teams to better allocate time and resources. In our institution, virtual care has been implemented in the ambulatory environment but has not been leveraged at a patient’s transition of care. Post-discharge virtual care may be a valuable modality to safely bridge care settings.
Purpose: We aim to create a Virtual Care Post-Discharge Program that would supplement the PCP follow-up appointment for higher risk patients and serve as a safety net for preventable harm. Given the educational mission at our institution and the lack of inpatient virtual care experience in residency curricula (4), the program would also provide a unique opportunity for residents to participate in virtual care in the hospital setting.
Description: In coordination with our system’s Population Health Management Team and MedStar ambulance service’s Mobile Health Team, we created a Virtual Care Post-Discharge Program. Patient inclusion criteria were: LACE ≥ 8, home disposition, payor as specified by Population Health Management and address as specified by MedStar ambulance service. Exclusion criteria included: primary psychiatric diagnosis, active substance abuse and pregnancy. Patients were identified for the program by the discharging physician. Once identified, an electronic order was placed for a virtual care post- discharge appointment. Case management was trained to assist in verification of eligibility and appointment coordination. The attending physician and the paramedic discussed with the patient at the bedside about what to anticipate with the visit. Patients were informed that they would not be charged for the visit. Appointments occurred within 24-72 hours after discharge. To ensure continuity and enhance education in transitions of care, virtual visits were performed by the discharging hospitalist and resident. During the visit the paramedic used a Tytocare device that allows for a virtual but comprehensive physical exam with audible heart and lung sounds. Other key components to the appointment included a detailed medication reconciliation, with medications collected from the home by the paramedic, and reinforcement of keeping their PCP follow-up. Early findings from the program suggest that an early post- discharge medication review may prevent serious adverse medication- related events. For example, it was identified that an elderly patient had organized their pill box with the entire week of an antihypertensive medication in one day. Intervention of such errors may not only reduce the risk of readmission but prove to be lifesaving.
Conclusions: A Virtual Care Post-Discharge Program may be a convenient and effective method to communicate with patients and assess their immediate post-discharge needs. A model that partners a community paramedic in the patient’s home with a virtual hospitalist, offers unique transitional support to complex patients and may lead to fewer adverse outcomes.