Primary care-staffed transition clinic may cut readmissions

A postdischarge transition clinic staffed by a primary care physician and other clinicians appeared to reduce readmission risk in a vulnerable patient population.

A postdischarge transition clinic staffed by a primary care physician (PCP) and other clinicians appeared to reduce readmission risk in a vulnerable patient population, according to research presented in November at the American Public Health Association's annual meeting in Chicago.

Lapses in care coordination from discharge to the primary care setting pervade the overall health care system and are “particularly precarious” for Medicare, Medicaid, and uninsured patients, said Vidya Chakravarthy, project manager in population health at Rush University Medical Center in Chicago.

“These patients often face a variety of psychosocial barriers, complex chronic conditions, and often will require transportation or medication assistance,” she said. “Particularly for the patients that do not have a primary care physician, it's often easier to return to the emergency department or hospital for their follow-up care, rather than trying to locate a primary care doctor on their own.”

So in September 2013, Rush opened a postdischarge transition clinic, staffed by a PCP, a licensed clinical social worker, a patient navigator, and a registered nurse, said Ms. Chakravarthy.

How it works

Once a hospitalist identifies a patient admitted to the general medicine unit as not having a PCP or not having a relationship with one, he or she refers the patient to a patient navigator from the centralized complex care coordination team at Rush. This is done regardless of payer, although the majority of referred patients have Medicaid or are uninsured, she said. “The transition clinic appointment is then scheduled before the patient's discharge from the hospital,” Ms. Chakravarthy said.

Immediately preceding that appointment, a licensed clinical social worker, who is part of the transition team, follows up with patients to address any psychosocial barriers that may prevent them from attending their appointments. The transition clinic patient navigator also helps connect patients to transportation assistance as needed, regardless of the insurance they have, Ms. Chakravarthy added. Then, at the time of the appointment, a PCP addresses any immediate clinical needs and assists with medication adherence, education, and postdischarge instructions, she said.

This transition team works to then address any remaining psychosocial barriers and help facilitate a connection with a PCP, either at Rush or in the community, who is conveniently located for patients and can address routine clinical and psychosocial needs. The transition clinic social worker continues to follow up with patients for 30 days after the clinic appointment to address any remaining barriers, as well as ensure they attend their PCP appointments and continue to build a long-term relationship, Ms. Chakravarthy said.

The clinic was designed for only 1 or 2 visits per patient, with the main goals of addressing any barriers to care and bridging the gap in the continuum of care between the hospital and the primary care setting, she said.

Reducing readmissions

The research team used a sample of 1,162 patients discharged between October 2013 and October 2014 from general medicine units at Rush with a postdischarge appointment scheduled within 30 days of discharge in either the clinic (24%) or with their PCPs (76%).

They compared 30-day readmissions between patients who completed an appointment at the transition clinic versus those who did not complete their scheduled clinic appointment. They also compared 30-day readmissions between patients who completed a clinic appointment and those who completed a follow-up appointment with their PCPs.

After controlling for financial and clinical characteristics and complexity of care, researchers found that patients who did not complete a scheduled transition clinic appointment were 3 times more likely to be readmitted than patients who completed a transition clinic appointment (20.3% vs. 8.7%; P=0.004). They noted no significant difference in 30-day readmissions between patients completing and not completing their PCP appointment.

“These results started to suggest that patients who capitalize on the support and resources that a transition clinic has to offer are less likely to be readmitted than patients who don't take advantage of these benefits. ... We [also found] that length of stay was shorter for patients who were referred to the transition clinic because the hospitalists and the residents knew that the patient would be caught in the safety net once they were discharged, so it made them more confident to put them back into the community,” Ms. Chakravarthy said.

Of patients scheduled at the clinic, about 11% completed their appointment, and about 13% did not, she said. (Beyond the data presented in the study, she noted that the no-show rate for the transition clinic is anywhere between 20% and 35%.)

In general, patients who attended a follow-up appointment 15 to 30 days post-discharge were 1.8 times more likely to be readmitted than those who followed up within 7 days, and Hispanic patients were 1.7 times more likely to be readmitted than patients with other ethnic backgrounds.


Ms. Chakravarthy noted several limitations to the study, such as the biases associated with its retrospective cross-sectional design, which does not allow researchers to control for the population. “The patients scheduled with a primary care physician were typically older and had Medicare, compared to patients who were scheduled in the transition clinic, who were typically younger and had Medicaid,” she said.

Also, the transition clinic was only open for about 13 months at the time of analysis, which accounts for a relatively smaller sample size, Ms. Chakravarthy said. “We also were not able to track utilization outside of Rush, which includes historical readmissions as well as subsequent readmissions to outside hospitals,” she added.

There is also no precise way to capture the complete impact of social factors because of limitations in the data, Ms. Chakravarthy noted.

“However, despite these limitations, the results do suggest that the transition clinic is a good model of care for patients who are not connected to a primary care physician because it provides good postdischarge access to care, both within and outside of the hospital setting, and helps connect the patient to the medical home to start establishing that long-term relationship,” Ms. Chakravarthy said.

Next steps

These results have created the opportunity to expand on this care model across the institution. Although a pharmacist hasn't been available to the transition team in the past, Rush is considering adding one to the transition team on a consultation basis, mostly for medication reconciliation, Ms. Chakravarthy said.

“We're also looking into possibly focusing on chronic diseases to see if we can target some common chronic diseases we bill to self-management programs to see if that has an effect on readmissions, as well,” she said. Researchers also want to further evaluate the difference in effectiveness between the clinic and community PCPs in managing complex chronic conditions, Ms. Chakravarthy said.

Other possible avenues include expanding referral sources to include the ED and subspecialty care services or further fostering relationships with PCPs in nearby federally qualified health centers to improve handoffs, she said. As Rush continues to evolve its clinic model, it will also begin to collaborate and consolidate with its other care coordination models to provide a more integrated way to manage the care of its vulnerable patients, Ms. Chakravarthy said.

“If these results do hold true as we continue to expand this model, then it could also potentially decrease the cost of care associated with complications and readmissions for these patients,” she said.