Transition Clinics

by Stefani Daniels, Managing Partner
Published on Oct 11, 2016

The care of the hospitalized patient has evolved over time, such that patients are sicker; length of stay has decreased; medical technology and knowledge have advanced; and new models of hospital-based care have evolved, such as the advent of hospitalists as the principal hospital-based providers. All of these factors have contributed to the complexity of coordinating transitions of care.


Five years ago, post-discharge clinics were minor blips on the radar screen.  Five years ago many experimental transition clinics closed their doors or converted to disease management clinics due to financial constraints. And five years ago hospitals weren't at risk for readmission penalties or excessive costs that impact global or bundled payment models.

With the changing marketplace transition clinics (TCs) are gaining acceptance and seem to be proliferating.

Out west where multispecialty groups and IPAs have for years accepted financial risk for patients - a precursor to the current ACO, global and bundled payment business models - many physicians see post-discharge care as a good clinical and business opportunity. That trend is spreading across the country as physicians and hospital leaders accept new payment models that offer incentives to keep patients healthy, out of the ED and avoid unnecessary hospitalizations.

Most TCs are an expansion of the hospitalist program staffed by a rotating group of hospitalists, a dedicated outpatient hospitalist team,  or the group's nurse practitioners.  At many TCs, all discharged patients are eligible with priority given to patients who have no community PCP or can't get an appointment with their PCP within a week or 10 days. TCs are not meant to be primary care centers but are rather targeted visits focused on the recent hospitaliztion: Does the patient understand their illness and why they were in the hospital; medication reconciliation, outstanding tests, or reinforcing what post procedure/surgical care they must follow. The post-acute clinic visits also have the ability to identify failures in the hospital's transition planning processes. These 'discharge failures' may include medications that don't match, patients who didn't know their discharge diagonsis, patients who weren't aware of their PCP follow up appointment and patients with misconceptions that may stop them from filling prescriptions or keeping specialist appointments.

Transitional care clinics should not be thought of as a stop-gap measures but an integral part of the organization's continuum of care program.  In accepting global risk, hospital execs realize that the frailest - most at risk - of the post-acute TC patients may need access to a team of care coordinators or specialty providers who can offer services even when the TC is closed. So there may be patients who are followed by transitional team members for months while the TC evolves into a medical home caring for the 'hotspotters' - those high end acuity patients who have particularly challenging chronic conditions and typically carry the majority of costs.  The goal is to emphasize the value of personal contact with patients before and after their discharge, as well as the organization's attempt to minimize excess costs, cut readmissions, help reduce ED visits, and try to overcome socioeconomic issues that impact health,