Background: Communication between hospital and outpatient clinicians is a key component to successful care transitions for older adults, yet this communication is frequently lacking. In addition, residents in academic medical centers are not routinely provided with feedback about post-discharge outcomes or opportunities for improvement.
Purpose: To implement weekly video conferences that utilize the electronic medical record (EMR) to discuss patients recently discharged from an acute care for elders (ACE) unit in order to improve communication, decrease hospital readmission rates, and improve transitional care education for resident physicians.
Description: In September 2018, we initiated weekly video teleconferences to include a multidisciplinary group of stakeholders from the ACE unit, a home health agency, and geriatric clinic serving a subset of ACE patients. A stakeholder analysis was completed to determine key individuals to include from each setting. Facilitated conferences are supported by a HIPAA-compliant video interface that allows participants to collectively view the EMR during the conferences. Multiple Plan-Do-Study-Act cycles were completed in the initial three months of this pilot. Modifications included: (1) implementing a script to clarify roles and prompt structured input, (2) outreach to ACE attendings and leadership to promote engagement, (3) adjusting timing during month-long rotations to improve resident participation, (4) discontinuation of home health participation due to low numbers of their patients, and (5) addition of discussions for currently-admitted patients.
To date, nine conferences have been completed and 55 individual patient admissions have been discussed. Nine of the 55 have been readmitted within 30 days (16.4% readmission rate). For the first two months of the pilot, the overall 30-day readmission rate for all inpatients discharged from the ACE unit has been 9.1%, which is lower than the 12.1% average from January-August 2018. Additional intervention time will allow assessment of whether changes in the average 30-day readmission rate compared to baseline are statistically significant. Planned next steps include evaluation of the educational value of conferences for resident physicians.
Conclusions: Key insights from innovation implementation include the need for discussions to deliver direct value to participants from both sites. This requires both adequate patient volume and discussion of patients for which both inpatient and outpatient clinicians have direct responsibility. Much as in-hospital handoffs benefit from standardization, we found participants appreciated a clear structure for the cross-site transition discussions. We demonstrated a multidisciplinary video teleconference intervention can be implemented to improve communication between inpatient and outpatient teams and may be a promising approach to improve transitional care education for resident physicians.