EXECUTIVE SUMMARY

The results of a recent study revealed a care transitions clinic can reduce emergency department discharge time and increase the clinic’s rate of successful transition to community primary care.

  • Intervening within 72 hours of discharge is important for patient engagement and facilitating education about their health and care management.
  • The care transitions clinic identifies the patient’s needs and refers them to all necessary services.
  • 80.6% of patients successfully connected with a primary care provider vs. the 59% success rate from the pre-transitions clinic cohort.

A care transitions clinic that provides newly discharged patients with a primary care provider (PCP) visit helped a health system reduce ED visits and hospitalizations.1

Researchers found a cohort of patients referred to primary care after discharge in the year before the transitions clinic opened in January 2019 averaged one emergency department (ED) visit in the three months after their referral. Patients seen at the transitions clinic in its first year averaged 0.33 ED visits in the three months after referral.

Patients referred to the transitions clinic recorded significantly fewer ED visits and hospitalizations post-referral than in the three months before referral.

“The role of this clinic is to make sure patients who could benefit from primary care access shortly after discharge from the hospital were able to get primary care,” says Lisa Rotenstein, MD, MBA, assistant medical director of population health and faculty well-being at Brigham and Women’s Hospital. “The clinic mostly was for patients who did not have a primary care provider, but have needs that should be addressed by a primary care provider after discharge.”

The clinic is located across the street from the main Brigham and Women’s Hospital campus, says Caroline Melia, RN, BSN, nurse coordinator at Brigham and Women’s Primary Care Transitions Clinic.

The transitions clinic was intended to serve Medicaid accountable care organization (ACO) patients, but its focus quickly expanded. “We’re working with some patients in their 70s and 80s who have never had a primary care physician,” Melia says.

Engaging with patients within 72 hours of discharge is important for educating them about their health and care management.

“We realized there was a need for patients to be seen by primary care — in short order — after discharge,” Rotenstein notes. “There was a demand for the service, and we started seeing patients with all insurance types, and that has continued.”

Most of the patients referred to the transitions clinic were discharged recently from the ED or hospital. They do not have a community primary care provider who they can see within 24 to 72 hours after discharge.

“I’m a nurse coordinator, and I do coordination of care and in-person nursing teaching,” Melia says. “There also is a practice assistant/medical assistant.”

Melia teaches patients self-care techniques related to their injuries and illnesses, including instructions about wound care, abscess treatment, burns, and diabetes.

The transitions clinic is intended to be a quick first stop for patients after discharge — not to replace a PCP. Melia helps patients find a PCP to provide continuing care.

“We identify any skilled needs of the patient, including physical therapy and speech therapy, and we refer patients to all specialists and any elder services,” Melia says. “If a patient needs a personal care assistant, we refer them to an agency that can help.”

Patients also learn about medication management and receive help with durable medical equipment through the transitions clinic’s services. “I tell patients we’re temporarily that primary care site,” Melia says. “Any agency that communicates with us, we sign the orders.”

Referrals to the care transitions clinic come from physicians, nurse practitioners, or nurse care coordinators in the ED and inpatient settings. The clinic is staffed by a PCP or nurse practitioner every weekday afternoon, a full-time nurse care coordinator, and a full-time medical assistant.

“We work with the case manager in the hospital to discuss what the plan is and how we’re going to maintain that plan after discharge,” Melia says. “I may make recommendations of adding a referral or visiting nurse.”

Melia makes sure patients or family caregivers will be home when medical equipment is delivered. She ensures patients receive their medication either before or right after they leave the clinic.

Hospital physicians benefit from better care transitions for their patients. “It provides peace of mind,” Rotenstein says. “It makes me feel like my patients have a clear plan and someone will follow up with them when they leave the hospital and are not plugged into community primary care.”

It also enables ED providers to make a quicker discharge because the care transitions clinic team can follow up with patients within 72 hours. The clinic has a good record of connecting patients to a PCP.

“At the time of the writing of the paper, 80.6% of patients were successfully connected with a new primary care provider, and we define that as being referred and keeping the first appointment with a PCP,” Melia explains.

When compared with the pre-transitions clinic cohort, the clinic’s rate of successful transition to community primary care is significantly improved. Only 59% of patients in the earlier cohort were successfully connected to a PCP, Rotenstein says.

The clinic’s work continued through the COVID-19 pandemic surges in 2020. “We were very busy and didn’t put it on pause,” Melia says. “In addition to having patients sick with heart failure, cancer, and other conditions, we were able to take post-discharge patients from the hospital who had been inpatients with COVID-19 and patients who were very sick and even intubated for 45 days.”

Clinic providers cared for patients both virtually and in person after discharge. They identified patients’ emotional needs and created a plan to provide patients with virtual social workers.

“The takeaway is this is an effective way to bridge transition to primary care providers, and it’s an approach that allows us to move patients into our care system and to make sure they’re getting the care they need,” Rotenstein says.

REFERENCE

  1. Rotenstein L, Melia C, Samal L, et al. Development of a primary care transitions clinic in an academic medical center. J Gen Intern Med 2021;1-8.