SHM Converge Scientific Abstract ePoster Gallery-Hospital Medicine, Digitial Platform, and Post-Hospital Transitions of Care

Pdf Summary

PEARL–Homeward is a Mayo Clinic initiative designed to improve the transition from hospital to home using a digital platform. Developed from the earlier PEARL video-visit program, it was expanded in March 2023 through collaboration among 12 multidisciplinary groups to support safer early discharge, seamless post-discharge follow-up, and remote patient monitoring (RPM).<br /><br />The program offers weekday video visits led by Advanced Practice Providers, with scheduling managed by a desk operations specialist. In June 2023, RPM was added for patients with COPD, hypertension, heart failure, and respiratory illnesses including COVID-19. The program is integrated into the EPIC electronic health record to simplify access and reduce the need for patients to learn new systems.<br /><br />Reported outcomes are encouraging. More than 800 patients have used post-hospital virtual care. The no-show rate fell from 35% to 15% after video visits and patient portal links were added. Over 30 APPs, representing about half of the division’s APPs, have participated. The program has also produced cost savings and reduced 30-day readmissions from 24.9% before launch to 21.9% afterward.<br /><br />Overall, PEARL–Homeward expands the hospitalist role beyond inpatient care to support patients after discharge. It demonstrates how hospital medicine teams can improve care transitions, maintain safety, and potentially reduce utilization. The program may serve as a model for other institutions seeking similar innovations.

Asset Subtitle

Sagar Dugani

Meta Tag

Author List Alexander Hills, Andy L. Seidl, Gina Kesselring, Holly A. Schenzel, M. Caroline Burton, Megan Nielsen, Riddhi S. Parikh, Sagar Dugani, Shangwe Kiliaki, Shant Ayanian

Category Innovations

Concept Hospital-to-Community Transition of Care

Concept Remote Patient Monitoring

Concept Digital Follow-up

Concept Readmission Rate

Concept Multidisciplinary Team

Distinguished Finalist

Presenter Organization Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN

Presenting Author Sagar Dugani

Track Transitions of Care

Keywords

PEARL-Homeward

hospital discharge

digital platform

video visits

remote patient monitoring

post-discharge follow-up

EPIC electronic health record

advanced practice providers

readmission reduction

care transitions

Hospital-to-Community Transition of Care

Remote Patient Monitoring

Digital Follow-up

Readmission Rate

Multidisciplinary Team