SHM Converge Scientific Abstract ePoster Gallery-Shatter Readmissions and Emergency Return Visit Through Transitional Care Innovations

Pdf Summary

The document describes a Post-Discharge Clinic (PDC) initiative created to improve transitional care for patients at a hospital facing chronic bed shortages and complex patient needs. The program aims to support patients during the vulnerable period after hospitalization by educating them and their families, identifying early warning signs of adverse events, encouraging medication adherence, and helping ensure a smooth transition to primary care.

The PDC uses three main workflows:  
1. <strong>Patient identification</strong> — inpatient providers identify patients who would benefit most from follow-up and notify Patient Navigation Coordinators (PNCs).  
2. <strong>Scheduling</strong> — PNCs directly schedule follow-up visits using a self-scheduling system and shared EPIC folder.  
3. <strong>Clinic flow</strong> — visits are streamlined and offered both in person and virtually, with additional support from finance, population health, and transitional care management services.

The primary goal was to assess whether the PDC reduced 30-day hospital readmissions and emergency department (ED) return visits. Results showed that the clinic was especially helpful for <strong>high-risk patients</strong>. Among these patients, the 30-day readmission rate was <strong>23% with PDC participation versus 36% without</strong>, and the 30-day ED return rate was <strong>35% versus 50%</strong>. No meaningful differences were found among low- and medium-risk patients.

Overall, the findings suggest that the patient-centered transitional care model contributed to fewer readmissions and ED visits, particularly in high-risk patients.

Asset Subtitle

Gilmer Rodriguez

Meta Tag

Author List David O. Meltzer, Gilmer Rodriguez, Lourdes Rodriguez, Monroe Chen, Virginia Lewis

Category Innovations

Concept Transitional Care

Concept Discharge Follow-up

Concept Hospital Readmission

Concept Emergency Department Return

Concept Post-Discharge Clinic

Distinguished Non-Finalist

Presenter Organization University of Chicago Medicine

Presenting Author Gilmer Rodriguez

Track Quality Improvement

Keywords

Post-Discharge Clinic

transitional care

hospital readmissions

emergency department visits

high-risk patients

patient navigation

follow-up visits

medication adherence

primary care transition

patient education

Transitional Care

Discharge Follow-up

Hospital Readmission

Emergency Department Return

Post-Discharge Clinic