Posts Tagged ‘follow-up clinic’

One-Fourth Operate Post-Discharge Clinics to Curb Hospital, Post-Acute Readmissions

June 4th, 2015 by Patricia Donovan

Dedicated post-discharge clinics address medication concerns so high-risk patients don't end up back in the hospital.


Almost one-quarter of healthcare organizations—24 percent—operate dedicated post-discharge clinics for patients recently discharged from the hospital, nursing home or ED, according to the April 2015 Care Transitions Management survey by the Healthcare Intelligence Network.

A post-discharge clinic is designed to address issues related to a patient’s recent hospitalization and ensure that the individual’s transition from hospital or post-acute facility to their primary care doctor is smooth.

In a 2014 presentation, Torrance Memorial Health System described the typical operation of its follow-up clinic, the Coordinated Care Center, which is focused on medication management, a key driver of avoidable hospital readmissions. The health system stressed that the clinic is not a replacement for follow-up primary care following a hospitalization:

“One tactic [for reducing readmissions] is to encourage each of our patients going home from the hospital and SNF to make an appointment at our post-acute clinic with the physician who does medication reconciliation. She asks the patients to bring in all the medications they were on before they went to the hospital and all those prescribed at the hospital.

“They then have a 45-minute conversation, discussing medication plans moving forward, which ones they should take and which they shouldn’t, making sure with teach-back methodology the patient has a clear understanding of expectations in terms of consuming medication once they return home later that day. Those appointments normally take place within the last 72 hours.”

A dedicated post-discharge clinic is one way to plug glaring gaps in care transition management: insufficient follow-up. More work is needed during the actual patient handoff to break down the top barrier to smooth care transitions identified by HIN’s fourth annual care transitions management assessment: communications between care sites.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN’s fourth annual analysis of these cross-continuum initiatives examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.