SHM Converge Scientific Abstract ePoster Gallery-A Virtual Hospitalists Clinic Decreased Congestive Heart Failure Readmissions

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The abstract describes the Acute Care Bridge Clinic (ACBC), a virtual hospitalist-led transition-of-care clinic created to improve post-discharge follow-up and reduce readmissions. The clinic uses Epic’s Risk of Unplanned Readmission Score (RURS) to identify high-, rising-, and low-risk patients and schedule follow-up visits within 48 hours, 4 days, or 7 days of discharge. Visits are conducted by video or telephone to remove barriers related to travel, cost, and clinic access.<br /><br />Over two fiscal years, the ACBC completed 2,345 transition-of-care visits for rising- and high-risk patients. During these visits, providers focused on symptom monitoring, medication reconciliation, recovery progress, follow-up testing, access barriers, and patient education. The most common interventions were medication reconciliation (42%), resource connection (31%), lab or diagnostic follow-up (17%), education and anticipatory guidance (8%), and escalation to higher-level care such as urgent care or readmission (2%).<br /><br />The model showed early success, especially for patients with congestive heart failure (CHF). Among CHF patients who had both a cardiology visit and ACBC follow-up within 2 days, the readmission rate was 0% (N=103), compared with higher readmission rates for visits occurring within 0–14 days (15.1%, N=93) and 0–30 days (19.4%, N=10). <br /><br />Overall, the ACBC demonstrates that a virtual, hospital medicine-driven transition clinic can improve access to care and reduce CHF readmissions. The authors suggest future studies should examine effects on other conditions, length of stay, morbidity, mortality, patient satisfaction, and broader resource use.

Asset Subtitle

Shadi Jarjous

Meta Tag

Author List Courtney Moore, Jillian Cozzubbo, Raizalie Gutierrez, Satinder Singh, Shadi Jarjous, Shuisen Li, Victoria Chestnut

Category Innovations

Concept Virtual Hospitalist-Led Transition-of-Care Clinic

Concept Discharge Follow-up

Concept Readmission Risk Score

Concept Transitional Care

Concept Patient Stratification

Distinguished Non-Finalist

Presenter Organization Jefferson Health-Lehigh Valley Region

Presenting Author Shadi Jarjous

Track Transitions of Care

Keywords

Acute Care Bridge Clinic

transition of care

readmission reduction

virtual follow-up

hospitalist-led clinic

Epic RURS

medication reconciliation

congestive heart failure

telehealth

post-discharge care

Virtual Hospitalist-Led Transition-of-Care Clinic

Discharge Follow-up

Readmission Risk Score

Transitional Care

Patient Stratification