SHM Converge Scientific Abstract ePoster Gallery-Collaborative Solutions to Identify Barriers for Scheduling Post-Hospital Discharge Primary Care Provider (Pcp) Follow-Up Visits

Collaborative Solutions to Identify Barriers for Scheduling Post-Hospital Discharge Primary Care Provider (Pcp) Follow-Up Visits

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This quality improvement project examined barriers to scheduling primary care provider (PCP) follow-up visits within 7 days after hospital discharge, since timely follow-up is linked to fewer 14-day readmissions. At the study institution, only 44% of discharged medicine patients completed a PCP visit within 7 days, and patients scheduled with their assigned PCP were more likely to complete follow-up.<br /><br />The team launched a multi-intervention initiative involving operations, ambulatory care management, and scheduling staff. Interventions included sharing data on the importance of timely follow-up, creating scheduling protocols to prioritize patients’ assigned PCPs, building an electronic health record Smart Form for schedulers to document real-time barriers, and regularly reviewing barrier data with stakeholders. Frontline schedulers helped design and refine the form.<br /><br />Between August 2022 and October 2024, 13,420 patients were included. A total of 13,823 Smart Form notes were created, and 29% documented at least one barrier. Among 2,896 known barriers, the most common were PCP availability (46%) and patient preferences (41%). These findings informed targeted interventions, such as adding blocked slots in PCP schedules for hospital follow-up visits, improving staff education, enhancing patient education at discharge, piloting video visits, and increasing clinic director outreach.<br /><br />The project showed that real-time barrier tracking and cross-department collaboration can support continuous quality improvement. Using iterative PDSA cycles, the team built a data-driven, patient-centered process that engaged schedulers as active partners in improving post-discharge continuity of care.

Asset Subtitle

Brian K. Le

Meta Tag

Author List Brian K. Le, Erin Dowling, Jeri Robertson, Jessica Leyva, Jessica Zhang, Monique Keeles, Wendy Simon, Yolanda Christenson

Category Research

Concept Primary Care Follow-up Visit

Concept PCP Availability

Concept Hospital Discharge

Concept Readmission Risk

Concept Patient Preference

Distinguished Non-Finalist

Presenter Organization UCLA Health DOM Quality Team

Presenting Author Brian K. Le

Track Transitions of Care

Keywords

primary care follow-up

hospital discharge

readmission reduction

scheduling barriers

quality improvement

electronic health record

Smart Form

PDSA cycles

care continuity

patient-centered care

Primary Care Follow-up Visit

PCP Availability

Hospital Discharge

Readmission Risk

Patient Preference