Background: Transitions from hospital to outpatient care are vulnerable points for missed follow-up and adverse events. Although timely primary care and specialty visits can improve outcomes, responsibility for arranging these appointments is often unclear, and workflows vary widely. We conducted a multi-stakeholder landscape assessment to map current post-discharge scheduling practices, identify barriers, and discover opportunities for system improvement at a large quaternary academic medical center.
Methods: Using a learning health systems approach, we conducted a mixed-methods assessment. Multidisciplinary inpatient stakeholders participated in a facilitated discussion on current workflows for arranging post-discharge follow-up, which informed the development of a structured electronic survey. The survey assessed responsibility for scheduling, timing, and methods of appointment arrangement, perceived barriers, and priority interventions for both specialty and primary care follow-up. We summarized responses descriptively and synthesized free-text comments to identify recurring themes and proposed solutions.
Results: Fifty health care providers across primary and consult hospital services responded. For specialty follow-up , common scheduling methods included electronic health record (EHR) discharge referrals (80%), EHR messages to clinic schedulers (65%), and phone calls to clinics (50%). Leading barriers included limited clinic capacity (45%) and insurance/authorization delays (40%). Most respondents indicated the specialty team should own scheduling responsibility (65%), though case management/social work (35%) and primary inpatient teams (30%) were also frequently involved, reflecting diffuse ownership. For primary care, 60% of services did not routinely schedule follow-up visits prior to discharge; when arranged, processes relied heavily on patients or their families calling to self-schedule. Key barriers included patients lacking an identified or in-network primary care provider (50%) and difficulty accessing external clinics (45%). Across both domains, respondents prioritized key areas for improvement, including dedicated discharge coordination, standardized workflows, discharge milestones, EHR automation, and increased post-discharge clinic capacity. Given that multiple responses were allowed for many items, the cumulative proportions for several questions exceeded 100%.
Conclusions: This landscape assessment revealed substantial variability, fragmented ownership, and access constraints in post-discharge scheduling for both specialty and primary care follow-up. Pre-discharge appointment scheduling was uncommon for primary care and inconsistently achieved for specialty care, with frequent reliance on patients and families to close gaps. Stakeholders identified clear needs: defined scheduling roles, centralized discharge coordination, EHR-enabled standardized workflows, and improved ambulatory capacity in primary and specialty care. This learning health system approach highlights opportunities to design more streamlined, coordinated post-discharge appointment workflows that strengthen care transitions and continuity across specialty and primary care settings while guiding future improvement efforts.