SHM Converge Scientific Abstract ePoster Gallery-Hospitalist-Primary Care Partnership to Enhance Transitional Access and Safety

Pdf Summary

The document describes a hospitalist-primary care partnership at the University of Chicago Medical Center designed to improve transitional care for a low-income, minority, and historically underserved patient population facing limited access to primary care. To address this gap, the Post-Discharge Clinic (PDC) provides hybrid transitional care through both virtual and in-person visits, with patients stratified by readmission risk and scheduled before hospital discharge.<br /><br />Within 48 hours after discharge, a transitional care nurse calls patients to review their clinical status, answer questions, and document the encounter in the electronic medical record. Patients at higher risk of readmission are seen in person within 7 days, while low- and moderate-risk patients are seen within 14 days. During visits, the clinic focuses on medication reconciliation, patient and family education, identification of adverse events, and support for adherence to treatment plans.<br /><br />The clinic aims to improve access to ambulatory care, patient safety, quality of care, and operational efficiency while helping patients connect with in-network primary care physicians. It also maintains communication with PCPs through EPIC, secure messaging, and phone calls.<br /><br />Results suggest strong performance: the PDC provides 100% access to primary care follow-up within 14 days, and high-risk patients seen in the clinic have a 33% lower readmission rate than those not seen. In February, 90.9% of new patients received an appointment within two weeks of discharge, far exceeding the institutional target of 42.4%. Both telehealth and in-person visits met or surpassed this benchmark.<br /><br />Overall, the program shows promise as an effective transitional care model that may reduce readmissions and improve post-hospitalization outcomes.

Asset Subtitle

Gilmer Rodriguez

Meta Tag

Author List Gilmer Rodriguez, Lourdes Rodriguez, Virginia Lewis

Category Innovations

Concept Post-Discharge Clinic

Concept Transitional Care

Concept Medication Reconciliation

Concept Hospitalist-Primary Care Partnership

Concept Transitional Access

Distinguished Non-Finalist

Presenter Organization University of Chicago Medicine

Presenting Author Gilmer Rodriguez

Track Transitions of Care

Keywords

transitional care

post-discharge clinic

hospitalist-primary care partnership

readmission reduction

telehealth follow-up

medication reconciliation

patient safety

primary care access

low-income underserved patients

University of Chicago Medical Center

Post-Discharge Clinic

Transitional Care

Medication Reconciliation

Hospitalist-Primary Care Partnership

Transitional Access