Background: The transition between hospital discharge and primary care follow-up is a vulnerable period for patients that can result in adverse health outcomes and preventable hospital readmissions. The COVID-19 pandemic has exacerbated this transitional period, as many patients have forgone their routine healthcare visits, lost touch with their primary care providers (PCPs), and lacked a point of contact for their health needs after leaving the hospital. In order to ensure safer transitions in care for patients, we launched a post-discharge Transitions in Care Management (TCM) clinic to serve patients discharged from NYU Langone Hospital Brooklyn, an urban safety net academic hospital that serves a racially diverse and socioeconomically vulnerable population in Southwest Brooklyn. The TCM visits were incorporated into residents’ existing primary care clinics. Our objective was to study how the TCM program affected transitions between inpatient admissions and outpatient care. We hypothesized that patients who participated in the clinic might have a decreased 30-day hospital readmission rate.
Methods: TCM visits were offered to patients prior to discharge from the general medicine service at NYU Langone Brooklyn who did not have a primary care provider or who could not get an appointment with their PCP within 10 days of discharge. Patients were given the option of in-person or virtual visits. TCM visits were scheduled with residents within 2 weeks of patient discharge. A templated note was used for TCM visits–questions focused on scheduled speciality appointments, discrepancies in medications prescribed at discharge, and whether the patient was connected to additional community resources. The primary outcome was the 30-day readmission rate for patients referred to TCM compared to patients who were not referred within the same timeframe.
Results: From October 2020 through October 2021, there were a total of 357 TCM visits out of 806 referrals placed (44% completion rate). There was a reduction in 30-day hospital readmission rate for patients who completed a TCM visit compared with those who were not referred 5% vs 15.9%; p < 0.001). There was also a reduction in readmission rate for those who were referred but did not complete their TCM visit compared to those who were not referred (8.4% vs. 15.9%; p < 0.001). Of the completed visits, 172 were in-person, 138 were virtual, and 47 were over the telephone. Patients were also more likely to show up to their virtual visits than their in-person visits (30% no-show rate for in-person vs. 12% no-show rate for virtual).
Conclusions: The 30 day hospital readmission rate was lower for patients seen as part of the resident-run TCM clinic at a safety net academic medical center. Interestingly, patients referred but who did not complete TCM visits still had a decreased readmission rate compared to those who were not referred. Future studies will examine any inherent differences between these patient groups, and analyze the factors that influence TCM referral and visit completion. Future studies will also analyze how the medium of visit (virtual vs. in-person) and specific interventions during the TCM visits (medication reconciliation, specialty appointments, community resources) influenced patients’ transition in care.
