SHM Converge Scientific Abstract ePoster Gallery-A Resident-Led Post-Discharge Clinic in an Urban Academic Safety-Net Hospital to Decrease 30-Day Hospital Readmission Rates

A Resident-Led Post-Discharge Clinic in an Urban Academic Safety-Net Hospital to Decrease 30-Day Hospital Readmission Rates

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Pdf Summary

This poster describes a resident-led Transitional Care Management (TCM) clinic created through a collaboration between NYU Langone Brooklyn, a Federally Qualified Health Center, and an internal medicine residency program. The clinic was designed to improve post-discharge follow-up for hospitalized patients without primary care doctors, with the goal of reducing 30-day hospital readmission rates.<br /><br />Patients discharged from the medical floor who lacked a PCP were offered either an in-person or virtual TCM visit. During the visit, residents used a standardized template to review clinical status, medications, medical equipment, and social work needs. Patients without a PCP were also given the option to establish ongoing primary care in the clinic.<br /><br />The study asked whether timely post-discharge care through a resident-run clinic would decrease 30-day readmissions. Results showed that patients who completed a TCM visit had the lowest 30-day readmission rate (5%). Patients who were referred but did not attend had a higher readmission rate (8.4%), while those not referred had the highest rate (15%).<br /><br />The findings suggest that a resident-led TCM clinic may help reduce readmissions in an urban safety-net hospital setting. The authors note that further analysis is needed to determine whether factors such as race, insurance status, prior PCP status, or type of visit affected outcomes. Future work will also examine whether TCM visits helped patients establish ongoing primary care after discharge.

Asset Subtitle

Patrick Li

Meta Tag

Author List Daniel Sartori, Marwa Moussa, Michael J. Martinez, Patrick Li, Rachael Hayes, Ramiro Jervis, Rebecca Grohman, Tiffany Kang, Vickie Kassapidis

Category Research

Concept Transitional Care Management Clinic

Concept Hospital Readmission

Concept Post-Discharge Visit

Concept Medication Reconciliation

Concept Readmission Rate

Distinguished Non-Finalist

Presenter Organization NYU Langone Health

Presenting Author Patrick Li

Track Transitions of Care

Keywords

Transitional Care Management

TCM clinic

resident-led clinic

post-discharge follow-up

hospital readmission

30-day readmission rate

primary care access

safety-net hospital

virtual visit

Federally Qualified Health Center

Transitional Care Management Clinic

Hospital Readmission

Post-Discharge Visit

Medication Reconciliation

Readmission Rate