One of the greatest frustrations for health care providers is obtaining timely follow‐up appointments. Hospitalists often feel compelled to extend a patient's length of stay because of their concern for patients being lost to follow‐up. Nowhere is this problem greater than in our unfunded patient population.


Through a collaboration between hospital administrators, case managers, outpatient physicians, nurses, and hospitalists, we created an ambulatory connections clinic to follow unfunded and/or medically complicated patients who were believed to be at high risk by the referring physician.


First, we embarked on a 3‐month trial period by collecting data from 1 hospitalist who referred at‐risk patients to a single case manager and outpatient physician for follow up on both the patient's social and medical needs. After demonstrating improved length of stay among these patients, our health system funded a full clinic to include 2 outpatient physicians, a “patient navigator” charged with contacting all patients prior to and after they were discharged from the hospital, and 2 clerks to collect data on patients referred to the clinic. In addition, the patient navigator scheduled an appointment for all “unfunded patients” with the county health care assistance program, which provides subsidized health care to county residents through county tax revenue. A 24‐hour, 7‐day‐a‐week hot line was created to schedule appointments with the medical clinic as well as the county health care assistance program. The health system also supported subsequent continuity appointments for patients until funding was obtained. Hospital days saved were determined by the referring hospitalist and were based on the additional number of days the patient would have remained hospitalized for further management prior to this clinic. Although subjective, this number accurately demonstrated how the physician's practice changed after the institution of this clinic. Over 10 months, 488 patients were referred to this clinic, resulting in 439 inpatient days saved and 53 admissions averted. Of those patients who made their initial clinic appointment, 91% received a subsequent follow‐up appointment with either a PCP or this clinic. Two hundred and seven patients received follow‐up with a specialist. Moreover, 76% of patients referred to this clinic were enrolled in local, state, or federal health care assistance programs. The most common diagnoses referred to this clinic included asthma/COPD (20%), diabetes (24%), malignancy (10%), and CHF (16%). Finally, the 30‐day readmis‐sion rate for this patient population was 4.9%, compared with a 5.5% readmission rate for unfunded patients in 2007. The cost of this program was estimated to be $400,000 annually.


Efficient, quality health care can be provided to socioeconomic and medically high‐risk patients by committing to providing appropriate continuity of care through a joint venture between the inpatient and the outpatient settings.

Author Disclosure:

M. Johnson, UTHSCSA, employed; L. Dodge, UHS, employed; L. Du, UHS, employed; P. Galindo, UHS, employed; G. McWilliams, UHS, employed; L. Sanchez, UHS, employed.