An individual effort to smooth transitions

A multicomponent intervention to smooth hospital discharges back into primary care involved a personal visit to every hospitalized patient.

Where: Kernersville Primary Care, a small primary care practice in Kernersville, N.C.

The issue: Reducing readmissions of elderly patients.


As a nurse practitioner working in primary care, Katie S. Wingate, DNP, AGNP-C, was well aware of the discontinuity of care her patients experienced when they were hospitalized. “We are the last independently owned primary care office in town,” she said. “When our patients go to the hospitals, we weren't in the loop at all. We were really frustrated not even knowing if someone was in the hospital. When they come in for follow-up, we don't know what happened.”

A successful strategy for managing patients post-discharge was to visit them in the hospital to coordinate care more of a check-in than a clinical visit Photo by iStock
A successful strategy for managing patients post-discharge was to visit them in the hospital to coordinate care, more of a check-in than a clinical visit. Photo by iStock

In addition to causing frustrations, these disconnects were likely increasing patients' risk of readmission, Dr. Wingate explained during a presentation at the American Association of Nurse Practitioners' annual conference, held in Philadelphia in June. “I did a brief literature review. I was really hoping that there would be some simple answer. That was naïve. I quickly found out that there is no simple answer.”

In her research, Dr. Wingate did find a multicomponent intervention that offered potential answers, the Transitional Care Model, and she modeled her efforts on it.

How it works

From June to October 2015, Dr. Wingate intervened every time one of her practice's community-dwelling elderly (65 years or older) patients was hospitalized with chronic obstructive pulmonary disease, heart failure, acute myocardial infarction, pneumonia, diabetes, or hypertension. The local hospital provided her with limited access to its electronic health record (EHR) system so that she would be notified.

“It would pop up: ‘John Doe is admitted.’ So I'd schedule a time to go over there and meet with him,” she said. The meeting was more of a check-in than a clinical visit, she explained: “How are you doing? What do you need? What questions do you have? Let me review your chart and go over this with you.” She'd also speak with the treating hospitalist or other inpatient care team member if possible.

After Dr. Wingate was notifed through the EHR that patients were discharged, she would call them within two days to review medications and make a follow-up appointment. She also saw patients for their follow-up appointments, which occurred within 14 days of discharge.

“Most of the time it was more like a week or less. That's when we reviewed the discharge summary and made sure all their medications were correct. If they needed any labs or diagnostic imaging or referrals, that got taken care of,” she said. Patients also received a patient-centered care plan, a booklet with information about their health conditions, medications, and red flags to seek care.


Thirty-six eligible patients from the practice were admitted while Dr. Wingate was conducting the project, but 20 of them were excluded from the project for various reasons, including that they were discharged before she could get to the hospital or that they declined to participate.

That left 16 patients she visited, 15 of whom she talked to on the phone and 11 of whom came to the follow-up office visit. One of the 11 was readmitted to the hospital and died there within 30 days of the initial discharge. The other 10 were not readmitted, for an overall readmission rate of 6.25%, which compares well with national and local averages.

“Of course, our findings were not statistically significant, but clinically significant? Maybe,” said Dr. Wingate. “If nothing else, the patients liked it and it was helpful to them.” One medication error was caught, and patients rated their satisfaction with the intervention at 4.9 out of 5.

Dr. Wingate's clinician satisfaction also increased. “It was so much easier to do the follow-up visit in the office, because I had been there throughout the process. I knew what had happened. I had the discharge summary that I wanted. It was just so much easier and less stressful, and I actually got to spend time with the patient and wasn't screaming and pulling my hair out,” said Dr. Wingate.


Once the challenge of getting the necessary information from the hospital was overcome, the biggest hurdles were patient buy-in and clinician time, Dr. Wingate said. She spent an average of 25 minutes on the hospital visit, seven minutes on the phone, and 23 minutes on the follow-up visit. The hospital visit wasn't reimbursed, but the intervention did allow the practice to bill transitional care management codes, which increased payment for follow-up office visits by $92 per patient in the project, compared to a 99214 visit.

Next steps

A shortage of time has prevented Dr. Wingate from continuing the project as a regular part of practice, despite her belief and the evidence that it did improve care. “We've lost a provider. We're swamped. We're going to try to do this when we get a little bit back on our feet,” she said.

Words of wisdom

“It shows us the challenges we face in primary care. There was definitely a lack of communication,” said Dr. Wingate. She noted that the project was well received by inpatient clinicians, but it didn't reduce the discontinuity between settings over the long term. “Did anyone call me in the office? No,” she said. “If I continue … I hope that will improve.”