The transition between the inpatient and outpatient setting is a high-risk period for patients. The presence and role of the primary care provider (PCP) is critical during this transition. This study evaluated characteristics and outcomes of discharged patients lacking timely PCP follow-up, defined as within 4 weeks of discharge.
This prospective cohort enrolled 65 patients admitted to University of Colorado Hospital, an urban 425-bed tertiary care center. We collected patient demographics, diagnosis, payer source and PCP information. Post-discharge phone calls determined PCP follow-up and readmission status. Thirty-day readmission rate and hospital length of stay (LOS) were compared in patients with and without timely PCP follow-up.
The rate of timely PCP follow-up was 49%. For a patient's same medical condition, the 30-day readmission rate was 12%. Patients lacking timely PCP follow-up were 10 times more likely to be readmitted (odds ratio [OR] = 9.9, P = 0.04): 21% in patients lacking timely PCP follow-up vs. 3% in patients with timely PCP follow-up, P = 0.03. Lack of insurance was associated with lower rates of timely PCP follow-up: 29% vs. 56% (P = 0.06), but did not independently increase readmission rate or LOS (OR = 1.0, P = 0.96). Index hospital LOS was longer in patients lacking timely PCP follow-up: 4.4 days vs. 6.3 days, P = 0.11.
Many patients discharged from this large urban academic hospital lacked timely outpatient PCP follow-up resulting in higher rates of readmission and a non-significant trend toward longer hospital LOS. Effective transitioning of care for vulnerable patients may require timely PCP follow-up.
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"These kinds of services are designed to ensure the safe and timely movement of patients from the hospital to their homes (Bray-Hall, 2012), while preventing avoidable readmissions and helping to ensure that positive health outcomes can be sustained (Naylor et al., 2011). Use of community health workers in this manner recognizes that low-socioeconomic status patients have lower access to postdischarge primary care (Asplin et al., 2005; Misky et al., 2010), receive poorer care while in the hospital (Rathore et al., 2006), and have higher risks of all-cause hospital readmission and death (Baker et al., 2002; Foraker et al., 2011). It also supports the philosophy that patient-centered medical care should follow individuals who are discharged from the hospital into the community (Lorig et al., 1999). "
[Show abstract][Hide abstract] ABSTRACT: The focus of community health workers on health disparities in vulnerable communities means that they address issues of poverty, while many recipients of psychiatric rehabilitation services live at or below the poverty line. Their focus on improving health in low-income populations of color is in line with some of our field's biggest challenges at this point in history, including poverty, cultural competence, and health comorbidities. By allying with community health workers we have the opportunity to extend our reach into new neighborhoods as well as to better serve our current clientele. By reaching out to local community health worker programs, conducting cross-training, and exploring new funding opportunities presented by health care reform, we may be able to enrich the multidisciplinary, collaborative ethos that makes psychiatric rehabilitation so relevant and effective. (PsycINFO Database Record
"If these tools are combined with other competencies such as motivational interviewing, their role as " health coach " can be easily demonstrated as defined by this type of community-based transition model (Hennessey & Suter, 2011). Home care nurses can also ensure that patients are followed up by their primary care practitioner in a timely fashion, as this is essential to improve care transitions (Misky, Wald & Coleman, 2010). In addition, there should be a thorough review of discharge instructions, followup appointments, and who the patient should call if there are problems. "
[Show abstract][Hide abstract] ABSTRACT: Our study described patient and caregiver experiences with care transitions following hospital discharge to home for patients with mobility impairments receiving physical and occupational therapy.
The study was a qualitative longitudinal interview study. Interviews were conducted at 2 weeks, 1 month, and 2 months post discharge. Participants were men, Caucasian, between 70 and 88 years old, and had either a medical or surgical diagnosis.
Breakdowns in communication in four domains impacted continuity of care and patient recovery: (a) Poor communication between patients and providers regarding ongoing care at home, (b) Whom to contact post discharge, (c) Provider response to phone calls following discharge, and (d) Provider-provider communication.
Improved systems are needed to address patient concerns after discharge from the hospital, specifically for patients with mobility impairments. Better communication between patients, hospital providers, and home care providers is needed to improve care coordination, facilitate recovery at home, and prevent potential adverse outcomes.
Preview · Article · Nov 2012 · Rehabilitation nursing: the official journal of the Association of Rehabilitation Nurses
"Problems in care transitions result in negative patient experiences, lack of appropriate follow-up care, and readmissions (Arora et al., 2010; Misky, Wald, & Coleman, 2010). Forster et al. (2003) studied 400 patients and found a 19% incidence of adverse events post-discharge. "
[Show abstract][Hide abstract] ABSTRACT: Care transitions involve coordination of patient care across multiple care settings. Many problems occur during care transitions resulting in negative patient outcomes and unnecessary readmissions. The purpose of this study was to describe the experience of care transitions from patient, caregiver, and health-care provider perspectives in a single metropolitan Midwest city. A qualitative descriptive design was used to solicit patients', caregivers', and health-care providers' perceptions of care transitions, their role within the process, barriers to effective care transitions, and strategies to overcome these barriers. Five themes emerged: preplanned admissions are ideal; lack of needed patient information upon admission; multiple services are needed in preparing patients for discharge; rushed or delayed discharges lead to patient misunderstanding; and difficulties in following aftercare instructions. Findings illustrated provider difficulty in meeting multiple care needs, and the need for patient-centered care to achieve positive outcomes associated with quality measures, reduced readmissions, and care transitions.
Full-text · Article · Oct 2012 · Clinical Nursing Research