Background: Hospital discharge handover is a primary metric for measuring healthcare quality and patient safety. Effective post-discharge follow-up (FUPD) reduces costly readmissions, adverse medical events, and preventable deaths. Despite the importance of hospital discharge follow up, the process of scheduling discharge appointments and the effectiveness of the process is often unclear to the medicine team and patients. We systematically analyzed the efficacy of the FUPD appointment creation process within the Stanford Internal Medicine Department’s (SIMD) Inpatient Unit.
Methods: Interviews of nurses, case managers, residents, chief residents, and attendings (N=8) were conducted to clarify the roles and current state of discharge appointment scheduling workflow. It was found that there was lack of communication between the medical teams and case management liaison responsible for scheduling appointments, which led to delay in scheduling and patients being missed, especially with weekend discharges and patients with primary care physicians (PCP) outside of Stanford network. Changes were made to the appointment scheduling workflow to optimize capturing all patients by time of discharge, and with special focus on external PCP follow up. To assess the impact of these interventions, patient charts pre and post changes (N=80, 40 pre, 43 post) were reviewed. Patient perspectives of the FUPD process and awareness were assessed through a 12 question survey.
Results: Data analysis revealed that pre-intervention, 71% of patients had internal PCP appointments scheduled at discharge, while only 18% of patients had external PCP appointments by discharge. 68% of subspecialty referrals were scheduled anywhere from 1-7 weeks after discharge, with high variation across Stanford specialty clinics. GI wait times are 50 days while GYN wait times are less than 10, though the n is small. Post intervention, we found a 36% increase in external PCP appointments created for patients discharged from the SIMD inpatient services, from 18% to 54% (p=0.02). Rates of internal PCP appointment scheduling remained the same. Analysis of patient perspectives suggest 82% have been told “having a follow-up appointment is important” with 68% aware of a PCP appointment being created.
Conclusions: Implementation of our recommendations for a streamlined electronic follow-up appointment scheduling process resulted in significantly increased numbers of patients discharged with an external PCP follow-up appointment. Chart review also demonstrated disparities in internal specialty follow-up times. Patient perspectives suggest clinicians are conveying follow-up appointment importance and that it is being received well by patients, but that administrative inefficiencies may deter FUPD appointment scheduling. Increased awareness of patient preferences for how appointments are made may increase PCP appointment attendance.