1. Hospital Discharge Transitions: Follow-up in Primary Care for High Risk Medicaid patients CFCC PCMH High Risk Patient working- group

2. Objectives To prevent hospital readmissions To improve the care of high risk patients through interactions with the PCMH team To improve the experience of health care providers in caring for high risk patients by utilizing PCMH team coordinated care

3. About CFCC FQHC serving Northeast Bronx Primary Care and specialty 10 minute walk from Weiler Hospital, Montefiore affiliate 10 Attending Physicians, 46 Categorical Internal Medicine Residents Traditional Scheduling 10 Attending Physicians 46 categorical residents Traditional scheduling - 80-100 clinic sessions per year ask questions

4. Transition Process Approximately 50 high risk hospital discharges per month, of which app. 20 are Medicaid Transition Team: Chronic Care RN’s and dedicated receptionist Each patient receives a phone call post- discharge from one of the CCRNs Initially, this phone call confirmed the post- discharge follow-up appointment and provided an opportunity for the patients to ask questions

5. How are we doing? Data for Quarter 2 2013: 50% called within 48hrs, 12% Visit within 48 hrs Chart Review from August: 77% called within 72 hrs, 94% had follow up appointment scheduled 77 % showed to follow up appointment

6. What more can we do? High risk working group began meeting weekly in August Working group membership is multidisciplinary: CCRNs, administrators, supervisors, MDs We conducted a chart review of our high risk discharges in July and August We developed several hypotheses about barriers to quality care for high risk discharges and enacted small scale interventions to test our hypothesis

7. Barriers to Quality Care Missed hospital discharge appointments –Personalized reminder calls –Calls addressing transportation needs Incomplete medication reconciliation –Over the phone med rec by CCRNs –Pre- and post-visit med rec by CCRNs at hospital discharge appointment Confusion about specialty appointments and follow-up appointments after the hospital discharge appointment –EMR flag with policy about mandatory follow-up within 2 months Lack of Access to Appointments within 48 hrs of discharge –Opening specific sessions for hospital discharges

8. Next steps Physician referrals of their “high risk” patients who could benefit from PCMH team coordinated care Summary data to track progress of initiatives Resident representation in the working group, resident referrals Continued hypothesis generation, new initiatives and evaluation

9. Results 9 In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law.