SHM Converge Scientific Abstract ePoster Gallery-Critical Role of Scheduling and Transitional Access to in-Out-of-Network Patients

Pdf Summary

The document describes how the University of Chicago Medicine Post-Discharge Clinic improved transitional care after hospital discharge by creating scheduling processes that ensure timely follow-up for both in-network (INN) and out-of-network (OON) patients. The goal was to guarantee access to post-discharge care within 7 days for patients at high risk of readmission and within 14 days for others, helping bridge gaps in care during the most vulnerable period after hospitalization.<br /><br />A major challenge was that Patient Navigator Coordinators (PNCs) did not have direct access to outpatient scheduling views and had to rely on central scheduling without patient input. To solve this, the clinic developed a system that gives PNCs better visibility into provider schedules so they can identify openings and offer appointments more efficiently.<br /><br />The clinic also implemented risk-based scheduling in collaboration with the Office of Clinical Transformation, using readmission risk to determine urgency. Patients with higher risk are prioritized for visits within 7 days, while others are scheduled within 14 days. If demand exceeds capacity, the clinic can open additional sessions to maintain timely access.<br /><br />The Post-Discharge Clinic provides both face-to-face and virtual visits, allowing flexibility for sicker patients, those unable to travel, and those who prefer remote care. Institutional financial support also helped make transitional care available to OON patients who meet criteria for close follow-up.<br /><br />Overall, these innovative scheduling and coordination efforts increased capacity, improved access for both INN and OON patients, and contributed to lower readmission and return visit rates among vulnerable populations.

Asset Subtitle

Gilmer Rodriguez

Meta Tag

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

Category Innovations

Concept Transitional Care

Concept Readmission

Concept Risk Stratification

Concept Clinical Outcome

Concept Post-Discharge Clinic

Distinguished Non-Finalist

Presenter Organization University of Chicago Medicine

Presenting Author Gilmer Rodriguez

Track Transitions of Care

Keywords

University of Chicago Medicine

Post-Discharge Clinic

transitional care

hospital discharge

risk-based scheduling

readmission risk

patient navigation coordinators

outpatient scheduling

virtual visits

follow-up care

Transitional Care

Readmission

Risk Stratification

Clinical Outcome

Post-Discharge Clinic