SHM Converge Scientific Abstract ePoster Gallery-Cost and Quality: Is Transitional Care Cost Effective?

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The document describes a cost-effective Post-Discharge Clinic (PDC) created to improve transitional care after hospital discharge without requiring a dedicated budgeted FTE. The program was developed using existing provider salaries, internal institutional resources, leadership support, and collaboration across hospital and primary care teams.<br /><br />The PDC targets patients from general medicine units who are at higher risk for readmission, especially those unable to see their primary care provider within seven days of discharge. Lower-risk patients are seen within 14 days if needed. All discharged patients receive a 48-hour follow-up call, and PDC visits include disease and medication education, medication reconciliation, review of adverse events, assessment of social support, and referrals to other services.<br /><br />The clinic was designed to support organizational goals, manage financial constraints, and improve quality outcomes such as readmission rates and emergency department (ED) return visits. Evaluation focused on operational costs, reductions in readmissions and ED visits, bed-day savings, and overall cost savings.<br /><br />Results showed that patients seen in the PDC had significantly lower 30-day readmission and ED return rates in the high-risk group compared with patients who did not use the clinic, with about a 33% improvement. Cost savings were estimated using the proportion of patients who avoided return visits, multiplied by direct ED visit costs and inpatient hospitalization costs based on average length of stay. The use of Transitional Care Management and new patient billing codes further supported the program’s financial sustainability.<br /><br />Overall, the PDC appears to be an effective, scalable, and cost-conscious transitional care intervention that reduces readmissions while aligning with institutional quality and financial goals.

Asset Subtitle

Gilmer Rodriguez

Meta Tag

Author List David O. Meltzer, Gilmer Rodriguez, Lourdes Rodriguez, Rajlakshmi Krishnamurthy, Virginia Lewis

Category Innovations

Concept Post-discharge Transitional Care Clinic

Concept Hospital Readmission

Concept Emergency Department Visits

Concept Readmission Risk

Concept Medication Reconciliation

Distinguished Non-Finalist

Presenter Organization University of Chicago Medicine

Presenting Author Gilmer Rodriguez

Track Value in Hospital Medicine

Keywords

post-discharge clinic

transitional care

readmission reduction

emergency department visits

medication reconciliation

follow-up calls

cost savings

high-risk patients

care coordination

billing codes

Post-discharge Transitional Care Clinic

Hospital Readmission

Emergency Department Visits

Readmission Risk

Medication Reconciliation