SHM Converge Scientific Abstract ePoster Gallery-Call to Action: Challenging the "Follow Up With Pcp" Culture

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This abstract argues against the routine discharge phrase “follow up with PCP” as an inadequate default, and calls for a culture shift in hospital medicine toward more structured peri-discharge planning. The authors note that safe discharge depends not only on medical stabilization, but also on social needs, care coordination, and communication with outpatient clinicians.  <br /><br />To assess current practice, the hospitalist group surveyed 61 hospitalists at a large urban safety-net medical center and reviewed discharge and readmission data. Survey results showed major gaps: 50% reported no communication with the primary care physician (PCP), and 47% said patients were discharged without a scheduled PCP appointment. Discharge data also showed an average of 3.2 subspecialty appointment requests per patient, but only 20% resulted in completed appointments. The hospital’s 30-day readmission rate was 12–15% overall and 20% for heart failure patients.  <br /><br />In response, the team piloted a readmissions reduction clinic (MVP) staffed by hospitalists, community health workers, and social workers. The clinic included transitional care visits, social determinants of health screening, and assistance connecting patients to resources and PCP follow-up. Early data from the pilot showed a 32% reduction in inpatient utilization.  <br /><br />The authors conclude that improving discharge outcomes requires standardized PCP communication, better scheduling of follow-up appointments, stronger inclusion of hospitalists in post-discharge programs, and increased attention to social needs. Ongoing efforts include building a PCP contact database, matching patients to PCPs based on insurance and resources, expanding referrals to the MVP clinic, and improving collaboration with primary care networks and multidisciplinary staff.

Asset Subtitle

Rachel Rubin

Meta Tag

Author List Claire Raab, Dharmini Shah Pandya, Kelly Hughes, Rachel Rubin

Category Innovations

Concept Peri-discharge Practices

Concept Care Coordination

Concept Follow-up Appointment Attendance

Concept Readmission

Concept Hospitalist Discharge Practices

Distinguished Non-Finalist

Presenter Organization Temple University Health System/Lewis Katz School of Medicine

Presenting Author Rachel Rubin

Track Transitions of Care

Keywords

hospital discharge

primary care follow-up

readmission reduction

transitional care

hospitalist communication

social determinants of health

care coordination

outpatient appointment scheduling

safety-net hospital

post-discharge planning

Peri-discharge Practices

Care Coordination

Follow-up Appointment Attendance

Readmission

Hospitalist Discharge Practices