Hospitals use post-discharge clinics to cut readmissions

With the industry focused on reducing readmissions, some hospitals are sending patients to post-discharge clinics to prevent them from returning.

Hospitalists, primary care physicians, or advanced-practice nurses operate the clinics, easing patients' transition from the hospital to home by explaining discharge instructions and ensuring they take medications correctly, reports The Hospitalist.

"We do medication reconciliation, reassessments, and follow-ups with lab tests," said Dr. Shay Martinez, medical director and hospitalist at Harborview Medical Center in Seattle. "We also try to assess who is more likely to be a no-show and who needs more help with scheduling follow-up appointments."

Harborview Medical Center's post-discharge clinic limits patients to three visits, then shifts their care to a medical home. Boston's Beth Israel Deaconess Medical Center gives patients a 40-minute post-discharge clinic visit or 30 minutes if they came from the hospital's emergency room (ER) and need follow-up care.

These hospitals may be on to something, as Tallahassee Memorial Hospital saw ER visits and readmissions for uninsured patients drop 68 percent, thanks to its after-care facility. "We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions," Tallahassee Memorial Hospital Chief Medical Officer Dr. Dean Watson told The Hospitalist.

However, since post-discharge clinics are newcomers to the healthcare landscape, there's almost no data to show whether they really provide lower rehospitalization rates or a return on investment.

Proven or not, methods like post-discharge clinics that ensure a smooth transition from the hospital are vital. One-third of adults don't see a physician within 30 days of discharge, according to study by the Center for Studying Health System Change. What's more, about 8.2 percent of adult patients returned to the hospital after 30 days, while 32.9 percent came back within a year of discharge, according to a press release yesterday. The study points to a lack of follow-up care as a source of avoidable hospital readmissions.

To learn more:
- read The Hospitalist article
- here's the press release