Background: Close outpatient follow up is a key element of a safe and effective transition to home after hospitalization. For a wide variety of patients, including those with myocardial infarctions, heart failure, and other conditions, interventions that encourage follow up can reduce readmissions and in some cases mortality. However, competing demands by the clinical team can lead to a suboptimal rate of discharge follow up appointments being made.
Purpose: We leveraged our electronic medical record to automate referrals to a dedicated patient access team in order to make patient appointments for discharged patients across 2 hospitals.
Description: At a pilot site of an 800-bed quaternary center, a workflow was developed which adopted existing discharge processes to automatically send referral requests for all patients on medicine service with a home disposition to a patient access call center. Patients, families and caregivers were engaged by the team to make appointments. From March to October 2022, 8,320 referral requests were made resulting in 4,249 appointments created, a 51.0% success rate. The major challenge was inability to reach the patient by phone immediately after discharge. Learning from this challenge, an on-site referral coordinator was brought to the hospital to directly engage with patients before they leave. This intervention corresponded with a year over year reduction in readmissions for a Medicare subpopulation. In the data available from March through June 2022, compared to the same period in 2021, the readmission rate was reduced from 19.1% to 14.9%. Subsequently, a second 600+ bed tertiary hospital site was included in the process and focused on the Medicare population only. From August to November 2022 169 referrals out of 189 requests were made, a success rate of 89.4%, higher than our initial site.
Conclusions: Leveraging nonclinical staff to make outpatient appointments can have a positive impact on care. Beyond freeing the clinical team to focus on patient care and reducing burnout, the impact may further include ensuring the benefits of close follow up such as medication reconciliation, prevention of medication errors, and early reassessment of clinical deterioration. Our process successfully used existing workflows to ensure this needed follow-up, is easily scalable across a large health system, and continues to be improved across multiple hospitals. Its impact is already starting to be understood on downstream quality indicators including an improved readmission rate in the Medicare population.