SHM Converge Scientific Abstract ePoster Gallery-Reducing Hospital Readmission Through a Virtual Transitions Clinic

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The Virtual Transitions Clinic (VT) at BSWH was created in August 2021 to reduce hospital readmissions and improve care transitions for patients at high risk of returning to the hospital. The initiative responds to the broader problem of readmissions highlighted by the Affordable Care Act and the Hospital Readmission Reduction Program, which increased transparency and financial penalties for excessive readmission rates.<br /><br />VT addresses a wide range of readmission causes, including disease progression and social determinants of health, by providing a patient-centered, telemedicine-based bridge from inpatient care to post-acute and primary care follow-up. The program uses an integrated, interdisciplinary model with centralized non-physician providers, physician oversight, and close collaboration with case management. Because it is embedded within the health system and EMR, VT can connect patients across the state to needed care resources.<br /><br />The implemented change focused on improving access, quality, and cost efficiency by offering virtual visits within 48 business hours of discharge and supporting the goal of standard hospital discharge follow-up within 7 days. The team helps coordinate between inpatient and ambulatory teams to ensure smooth transitions and continuity of care.<br /><br />An example case shows how VT can identify and solve post-discharge gaps: a primarily Spanish-speaking patient with heart failure was discharged home with VT and home health. At the initial VT visit, staff discovered she had lost part of her discharge instructions and had not yet obtained all medications. VT coordinated with home health, reconciled medications, updated her pill box, and provided disease management counseling.<br /><br />Lessons learned indicate that connecting with patients immediately after discharge improves follow-up with primary care, helps reduce readmissions in moderate-to-very-high-risk patients, and supports a more reliable recovery pathway after hospitalization.

Asset Subtitle

Andrew J. Widmer

Meta Tag

Author List Andrew J. Widmer, Justin Johnson, Layne Stone, Shirley Clendenin

Category Innovations

Concept Virtual Transitions Clinic

Concept Hospital Readmission

Concept Post-discharge Care

Concept Care Coordination

Concept Telemedicine

Distinguished Finalist

Presenter Organization Baylor Scott and White Health

Presenting Author Andrew J. Widmer

Track Transitions of Care

Keywords

Virtual Transitions Clinic

hospital readmissions

care transitions

telemedicine

post-discharge follow-up

heart failure

medication reconciliation

patient-centered care

case management

discharge planning

Virtual Transitions Clinic

Hospital Readmission

Post-discharge Care

Care Coordination

Telemedicine