by Webmaster
Published on Jun 23, 2016

As the goals of care change over time, everybody is going to have to reinvent themselves and the post discharge clinic is an initial strategy that can actually make a difference. But hospitals and hospitalists will have to be strategic and figure out what's valuable as they move to more comprehensive transitional care programs.

We received many comments regarding the post on the  creation of post-acute-resource-centers (PARC)  which hospitals are developing to facilitate the post acute services for patients being discharged from the hospital. Some respondents mentioned that as patients' nurses are taking on more of the discharge planning processes for 'routine' discharges - in preparation for the implementation of the proposal CoP discharge planning changes - the PARC is an essential component to ensure that the patients' nurse stays visible at the bedside and isn't overwhelmed by the many tasks that have to be completed to prepare for every hospital discharge.  

Among the comments we received was from a hospital care manager in Boston who said that her hospital combined their PARC with the opening of a post discharge clinic (PDC). Although very leery about crossing the line between inpatient and outpatient and wanting to avoid any turf battles with local primary physicians, the hospitalists at this Boston hospital saw a post discharge visit as a serious solution to prevent unnecessary readmissions and control avoidable costs.  

The visit is for high-risk patients who do not have a primary care physician or who can't get an appointment with their primary care physician within 7-10 days of discharge.  The patients see the same hospitalist who discharged them and, to avoid any primary care overlap, the visit is entirely focused on a review of the care the patient received in the hospital, the medication reconciliation to ensure that the patient is taking the prescribed meds, any outstanding tests or test results, and follow up on things that need to be done. 

Keeping post hospital follow-up visits within the hospitalist team helps the hospitalists identify failures in the organization's discharge process. They capture those 'failures' and use the data to help the care team improve processes.  The list of 'failures' includes such things as medications that don't match, patients who don't know their discharge diagnosis, patients who aren't aware of their primary care follow up appointments, and patients with misconceptions that stop them from filling prescriptions. Some of this feedback has helped the way the hospitalists, the patients' nurses and the care managers approach discharges.

We see PDC visits as providing good business and clinical opportunities. Not only is it a strategy to avoid readmissions and the associated penalities, but its also an integral part of the development of a comprehensive transitional care program.  When hospitals and hospitalists get together to accept global risk, bundled payments or participate in ACOs, post discharge transitional care becomes a priority.  The Post Discharge Clinic is a small component in the bigger picture of the new value based healthcare environment.