Background: Improper care transitions account for more than 12 billion dollars in estimated added health care costs. In a prospective observational study performed at our institution to identify gaps in care transitions, only 37% of primary care physician’s (PCP’s) were contacted by hospitalist upon discharge. The objective of this study was to evaluate the effect of a resident transition of care champion (TOCC) on metrics of transition of care (TOC).
Methods: We conducted a prospective observational study of 306 patients admitted to the inpatient service of two acute care hospitals, one with TOCC group and the other without (control group ) over 16 weeks period. Primary study end points were: a) PCP contacted upon discharge, b) follow up appointment made upon discharge. Test hypothesis was “The presence of TOCC is associated with a higher occurrence of primary end points”. Demographic data, admitting diagnosis and events during hospitalization were recorded. Data were analyzed using SPSS 20.0.
Results: Out of 306 patients enrolled, 156 were in TOCC institution and 150 were in control institution. Occurrence of primary endpoints was significantly higher in TOCC institution compared to control [PCP contact upon discharge 89.7 % vs 65.1 %, p= 0.001) and follow up appointment (82 % vs 67.1 %, p= 0.003)]. Presence of TOCC at the institution was a significant independent predictor of the primary end point (OR = 4.2 , 95% CI [2.1 – 8.3], p = 0.0001).
Conclusions: Our study shows that appointment of TOCC, significantly, increases TOC as measured by direct physician to physician communication. Implementing protocol based checklist and trigger for communication may further improve TOC between inpatient team and outpatient providers.