1. Improving care transitions at Harborview Medical Center Frederick M. Chen, MD, MPH Chief of Family Medicine Associate Professor, University of Washington

2. The new norm: Discontinuity 1

3. High risk transitions of care 20% of Medicare patients are readmitted within 30 days; 34% within 90 days. Estimated cost upwards of $17 billion annually. 4 50% of patients have a medication error; up to 85% have discrepancies on inpatient vs. outpatient medication lists on admission or discharge. 5,6 20% of patients suffer an adverse event in the 3 weeks post- discharge, the majority of which are medication related, followed by procedure related, then abnormal labs. 7 Communication between PCP and hospitalist is poor – direct communication 3-20%. Discharge summary by first post- discharge visit 12-34%. 8

4. Family medicine continuity rounding service Goals Provide continuity and connection for patients Coordinate discharge planning Structure Prioritized rounding on new admissions and impending discharges on all medical / surgical services Physician rounder; Clinic nurse designated for transitions Communicate with primary team and PCP Reconcile medication and problem lists Make follow-up appointments within 14 days

5. Methodology Data obtained from AMALGA database between 2/1/12 – 2/1/13, including HMC admissions, ED stays, and FMC visits for our patients Outcomes Primary – readmission or ED visits within 30 days for any diagnosis Secondary – patient attendance at f/up appointment w/in 14 days

6. In other words… Prior to Continuity Visit 2/1/2012 - 8/31/201 Continuity Visit 9/1/2012 - 1/31/2013 P-value Total readmitted12.12% (16)9.23% (6)0.54 ED visit within 30 d (for any reason) 18.18 % (24)9.23 % (6)0.10 FMC f/up w/in 14 d40.15% (53)47.69% (31)0.31 23.8 % reduction in 30-day readmission rate 49.2 % reduction in 30-day ED visits 18.7 % increase 14-day FMC visit attendance Results

7. Continuity works Van Walraven, et al, showed an independent association of follow-up visits with PCP with decrease in urgent admissions. 9 Gill and Mainous demonstrated higher outpatient provider continuity was associated with a lower likelihood of hospitalization, especially from a chronic condition. 10 Misky, et al, found patients lacking timely PCP f/up were 10 times more likely to be readmitted. 11

8. Strategies: Enhanced discharge services Incorporating disease specific discharge instructions, discharge telephone monitoring, hospital-run clinics lowered readmission rates 25% ->15%. 12 Hospitalist-run clinic for immediate post-discharge follow-up decreased 30-day risk of death or readmission by 5%. 13 Transitional care model 8/9 RCTs evaluating readmission showed significant decrease at 30 days, methods centered around enhanced discharge, RN driven care coordination and home visits. 14 3/9 showed decreased readmission rates at 6-12 months; methods were home visits and telehealth. 15,16,17 These interventions were based out of the hospital, not a PCMH.

9. AFTER CARE CLINIC: Linking Patients to Primary Care September 2014

10. History “The safety net for the safety net” Founded 2008 Goal: bridge unaffiliated patients from ED/inpatient discharge to primary care Grown from few sessions per week to full clinic schedule

11. Clinic Visit Patients referred from ED/Inpatient Typically appointed with 1-2 weeks No walk-in visits (ED high utilizer exception) Reminder call day before During the visit: – Urgent issues addressed – Follow-up with PCP arranged – Patient leaves with appt date/time & PCP name No-show patients are invited back

12. Future Directions Ensuring safe transitions Reducing no-shows in ACC Reducing no-shows with PCPs Streamlining process for PCP referral Tackling “assigned PCP” Engaging patients in the process