Background:
Transitions from hospitals to the ambulatory setting are high risk periods for patients. The advent of the Patient‐Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) provide an opportunity for true collaboration in which both inpatient and outpatient providers have a vested interest in promoting safe transitions and in which each can contribute appropriate components of the intervention.
Purpose:
Our goal was to develop, implement, and refine a multi‐faceted, multi‐disciplinary discharge intervention with contributions from hospital and primary care personnel across two hospitals and several PCMHs within a Pioneer ACO.
Description:
As part of a $1.9 million grant from the Patient‐Centered Outcomes Research Institute, we assembled a multi‐disciplinary team, including a patient‐family advisory council, to help design and refine the intervention. The intervention consists of several components: inpatient pharmacist‐led medication reconciliation and patient counseling; coordination of care and patient education from an inpatient “discharge advocate” and PCMH “responsible outpatient clinician;” a structured visiting nurse intervention; post‐discharge phone calls and a structured multi‐disciplinary follow‐up visit in the PCMH; and optional programs for selected patients, including palliative care consultation, home pharmacist visits, a CHF telemedicine program, and community‐based health coaches. The goals and preferences of patients are prioritized throughout the intervention, and providers work to ensure seamless exchange of information. During the first 6 weeks of pilot testing, the intervention was implemented among 36 patients, most of whom received various components of the intervention (Table). Ongoing team meetings have led to iterative refinement of the intervention and buy‐in of all involved personnel. Challenges have included having time to counsel patients prior to discharge, ensuring PCP follow‐up, avoiding redundancy among the roles of various personnel, and limiting the number of providers in order to engender trust and avoid overwhelming patients. To date, 5 patients (14%) have had an unplanned 30‐day readmission, each of which triggers a patient‐family interview and surveys of inpatient and outpatient providers to assess preventability and allow for further refinement of the intervention over time.
Conclusions:
Health care reform efforts that move away from traditional fee‐for‐service and towards more integrated models provide the opportunity to develop comprehensive approaches to improving care transitions. Multi‐faceted interventions such as that described here have great potential to improve patient‐centered outcomes for patients as they transition out of the hospital.
