Implementing Primary Care Follow-up for High-Risk Vascular Surgery Patients
AuthorFord, Elizabeth A.
AdvisorCosta, Linda L.
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AbstractProblem & Purpose: Since 2013, hospital Medicare reimbursement has been linked to hospital performance and quality of care. Hospitals are required to report their 30-day readmission rate linking payment to the quality of hospital care, encouraging hospitals to develop strategies to improve communication and care coordination to engage patients and caregivers in discharge plans to reduce avoidable readmissions. In a large urban academic medical center, the 30-day hospital readmission rate for the fiscal year of 2020-2021 was 17.5%, which is above the department target of 13.5% and national surgery average of 15.6%. One method to reduce readmissions and provide care continuity is to have a patient visit a primary care provider within two weeks of discharge. The purpose of this quality improvement initiative was to target vascular surgery patients discharged to home who are at high risk for readmission and arrange a primary care provider (PCP) follow-up appointment within two weeks of hospital discharge. Methods: The discharging provider utilized the “HOSPITAL score for Readmission” validated tool to identify patients categorized as high-risk for an unplanned 30-day readmission and ensured follow-up appointments with a PCP. For identified patients without an established PCP or whose PCP could not accommodate an appointment, a hospital-based transitional care clinic (TCC) appointment bridged medical care until PCP establishment or resumption of care respectively. Results: A total of 158 vascular surgery patients were discharged to home over 15 weeks with 30 patients (19%) having an unplanned readmission within 30-days from discharge. The high-risk patients who did not receive the intervention had a higher readmission rate (30.4%) than the high-risk patients who did receive the intervention (21.4%). Conclusions: A review of the PCP/TCC visits indicated medical management of various chronic conditions (HTN, anemia, depression) and acute conditions (hypotension, pain, UTI), which may have contributed to the lower readmission rate for the high-risk group receiving the intervention. Increased usage of the transitional care clinic identified a gap that patients continue to require assistance with establishing care with a PCP and further process change in the future is needed to ensure successful transition for all patients.
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Identifier to cite or link to this itemhttp://hdl.handle.net/10713/20890
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Except where otherwise noted, this item's license is described as Attribution-NonCommercial-NoDerivatives 4.0 International