Reduction of 30‐ and 90‐Day Composite Ed Visits and Readmissions Through a Structured, Multidisciplinary Hospital Follow‐Up Clinic

Background:

Timely and structured follow‐up after a hospitalization may reduce ED utilization and readmissions. We evaluated whether patients who attended a structured, multidisciplinary hospital follow‐up (HFU) clinic had fewer composite outcomes (ED visits or readmissions) at 30 and 90 days compared with risk‐matched controls.

Methods:

We conducted a pilot of a multidisciplinary HFU clinic including a pharmacist, social worker, and physician team between April and August 2012 within our academic internal medicine clinic (IMC). Patients discharged from our academic hospital were provided HFU clinic appointments within 7 days (median) and were called 1–2 days prior to the visits. HFU visits lasted 1 hour and included medication reconciliation; teach‐back of care plan revisions, medications, and red flags; and instructions for after‐hours care. Care management was engaged during visits as needed. Clinic slots were limited during this pilot, and some patients received usual care rather than HFU clinic appointments. The intervention group included any IMC patient who completed an HFU clinic visit. We randomly selected a risk‐matched control group from IMC patients who were not seen in the HFU clinic following a hospitalization during the same period. Multivariable Cox proportional hazards regression modeling was used to compare the time to composite outcomes of 30‐ and 90‐day ED visits or readmission. We adjusted for covariates that were different between groups at baseline or had the potential to be a confounder (i.e., age, sex, asthma/COPD, depression, IMC visits in the year prior, and ED visits or hospitalizations in the year prior). The intervention group included 47 IMC patients with 48 hospitalizations followed by an HFU clinic visit. The risk‐matched control group included 45 patients with 48 hospitalizations during the same period who did not have an HFU clinic visit following hospitalization. Two reviewers abstracted data for comorbidities, ED visits, and hospitalizations through chart review; the same exclusion criteria were used for both groups.

Results:

The average patient age was 61 years, 57% were women, and 28% had heart failure. Within 30 days, 23% of the intervention group versus 44% of the control group had at least 1 event (ED visit or hospitalization); within 90 days, 35% of the intervention group versus 58% of the control group had at least 1 event. Compared with the control group, the intervention group had a lower hazard ratio (HR) for a first ED visit or hospitalization at 30 days (HR, 0.42; 95% CI, 0.19–0.93; P = 0.032) and 90 days (HR, 0.48; 95% CI, 0.25–0.94; P = 0.033). The intervention group also had a lower median time to IMC follow‐up compared with the control group (7 versus 14 days, P = 0.0005).

Conclusions:

A structured, multidisciplinary HFU clinic reduced time to follow‐up after hospitalization and reduced 30‐ and 90‐day composite outcomes (ED visits or readmissions). Additional evaluation of cost could provide insight into the sustainability of this clinic.