Background: Patients discharged from the hospital often face challenges accessing timely and effective follow-up care after discharge from the inpatient setting. Prior studies have demonstrated that lack of primary care clinic access can raise patients’ risk of readmission (1, 2). Effectiveness of a virtual transitions of care clinic has not been reported in the literature to date.

Purpose: UCSD launched the Virtual Transitions of Care (VToC) clinic with the aim of improving patient safety and reducing readmissions for patients who were previously experiencing challenges obtaining timely post-discharge care.

Description: The VToC pilot created a dedicated virtual clinic to follow patients discharged from Hospital Medicine services at UC San Diego Health. The clinic included hospitalists, a medical assistant, case managers, and population health support staff. Visits were conducted with video or telephone. A total of 77 patients were recruited and seen between November 2019 and March 2021. Patients were included if they were discharged from a hospital medicine service, had an affiliated UCSD primary care physician (PCP), and had a LACE+ score of >50. LACE+ is a validated index used to predict 30-day death or urgent readmission. Patients in the VToC group were compared with a control group of patients discharged from hospital medicine services in 2019, including the pilot study period (November 2019 to March 2021). The number of days from discharge to days seen in a clinic were measured. Readmission rates over a 30-day period after discharge were analyzed through chart review with patients seen in VToC clinic and the control group. Patients seen in the VToC pilot were provided with a survey to rate their experience in the clinic on a scale of 1 to 10 (10 being the best care). Additionally, hospitalists who participated in the VToC pilot were asked to complete a survey after each encounter to characterize the clinic’s contributions to patient care.Patients in the VToC pilot were seen an average of 3.92 calendar days after discharge compared with 19.02 days after discharge for the control group. Among patients with LACE+ score of 50-65, patients seen in VToC had a readmission rate of 6.7% compared with 10.3% of admitted patients during the pilot study period (November 2019 to March 2021) and 14.2% for patients admitted in 2019 (Figure 1). Patients in VToC were also surveyed to rate their experience with the clinic. Among patients who participated in the survey, the average clinic visit rating was 9.71 on a scale of 1-10 with 10 being the best care. Hospitalists who participated in VToC were also surveyed and reported positive contributions of the clinic; 40% reported referred or expedited specialist follow up, and more than 50% reported counseling about medications (Figure 2). Overall, patients in the VToC pilot had sooner post discharge care, reduced rates of readmissions, high satisfaction, and opportunities for improved medication safety.

Conclusions: The VToC pilot study demonstrated improved access to post discharge care, reduction in in readmission rates, and positive patient satisfaction scores. Further studies will include a longer duration and patients with PCPs outside of the UCSD system. Additional data should be collected on impact of VToC on medication reconciliation and processes to improve transitions of care. VToC offers a patient centered service to improve access and safety while forging growth between inpatient and outpatient settings.

IMAGE 1: Figure 1: Readmission rates of VToC patients, stratified by LACE +, compared to 2019 Calendar Year Hospital Medicine benchmark as well as Hospital Medicine benchmark during time period of the pilot.

IMAGE 2: Figure 2: Results of VToC provider survey, conducted between 12/3/20 and 3/31/21. Hospitalists were surveyed after every clinic session and asked to free text value add actions they contributed for each patient. Text responses were analyzed and grouped into common themes, here reported out in frequencies.