Background: Shifting dynamics present unique opportunities for inpatient providers to enhance outcomes during transitions of care (TOC) as hospital medicine rises as a specialized field. It is well established that gaps in TOC can lead to unfavorable outcomes for patients and healthcare systems alike including increased morbidity, complications, readmissions, and costs. While TOC visits are often relegated to the ambulatory care setting, our hospital medicine division has proactively established a novel approach to TOC via the Acute Care Bridge Clinic (ACBC). The ACBC is a virtual entity that integrates evidence-based resources and approaches, leverages technology to enhance patient access to care, and empowers providers to improve TOC outcomes via the provision of follow-up clinical care.
Purpose: The Purpose of the ACBC is to bridge care gaps between the inpatient and outpatient areas as well as population health programs to ensure a safe and effective patient TOC post discharge and decrease risk of readmission.
Description: Risk of Unplanned Readmission Score (RURS), an Epic predictive model2, was utilized at the time of discharge to risk-stratify patients so they can be preferentially scheduled with the ACBC vs. the PCP as first option for TOC based on agreed upon scheduling guidelines that drive high risk and risking risk patients to the ACBC. The RURS was also used to determine the interval between discharge and the ACBC appointment within 48 hours (high risk), 4 days (rising risk) and 7 days (low risk). During two fiscal years the ACBC facilitated 2345 (N) rising and high-risk TOC visits. Virtual video or telephone visit formats and existing logistical resources were leveraged to enhance access and overcome overhead, administrative and travel barriers related to an in-person clinic. TOC visits were conducted in standard format, gathering subjective and objective data to conduct assessments and formulate a comprehensive plan. Specific attention was placed on recovery progress, symptom monitoring and management, medication reconciliation, access barriers, follow-up testing and appointments, and anticipatory guidance as well as addressing questions or concerns. Of the N =2345 rising and high-risk visits in the ACBC, interventions to bridge TOC gaps included medication reconciliation review/intervention (42%), follow-up diagnostic labs/monitoring (17%), resource connection/provision (31%), education and anticipatory guidance (8%), and referral to a higher level of care including urgent care or readmission (2%). Most notably, a significant reduction of readmission rate was appreciated for patients with CHF who had a Cardiology visit post discharge and were also evaluated in ACBC within 2 and 7 days (0% N = 103; 13.4% N= 93) as compared to 0-14 days and 0-30 days visits (15.1% N= 93; 19.4% N= 10).
Conclusions: By leveraging resources including the RURS risk stratification tool and the virtual clinical platform, our hospital medicine led ACBC model has demonstrated early and remarkable success in the creation and launch of an impactful intervention which has positively impacted readmission rates for CHF patients and their access to TOC services. Future directions include analysis to evaluate the impact upon readmissions for additional comorbidities, LOS, morbidity and mortality rates, access to care and resources, as well as patient satisfaction.