SHM Converge Scientific Abstract ePoster Gallery-Uchicago Post-Discharge Clinic: Strategy and Outcomes on Access and Readmissions

Pdf Summary

The University of Chicago Medical Center created a Post-Discharge Clinic (PDC) to improve transitional care for a complex patient population facing bed shortages and high post-discharge risk. The clinic’s goals were to ensure timely follow-up within 14 days after hospital discharge, identify and address adverse events, and reduce readmissions and emergency department (ED) returns.<br /><br />The PDC was designed to support patients who needed close follow-up, including those with pending tests, medication changes, discharge concerns, or difficulty accessing primary care. If patients could not see a primary care physician (PCP) within 7–14 days, they were scheduled into the PDC. High-risk patients were prioritized for follow-up within 7 days when possible.<br /><br />Results showed that the PDC significantly improved access to care. Patients were seen in the clinic in less than 14 days after discharge, while the average wait time for a new primary care appointment at UCMC was 61 days. The clinic also helped identify and intervene on pharmacological and medical adverse events through medication reconciliation, patient education, and coordination with PCPs.<br /><br />In terms of outcomes, patients seen in the PDC had 33% lower 30-day readmission and ED return rates compared with similar patients who did not use the clinic, across both low- and high-risk groups.<br /><br />To make the model work, UCMC developed three workflows: patient identification, scheduling, and clinic flow. Scheduling was streamlined through Patient Navigation Coordinators using an EPIC shared list, with support for virtual and in-person visits, out-of-network cases, and 48-hour post-discharge nurse calls.<br /><br />Overall, the PDC improved access, care coordination, and short-term outcomes after hospitalization.

Asset Subtitle

Gilmer Rodriguez

Meta Tag

Author List Gilmer Rodriguez, Lourdes Rodriguez

Category Innovations

Concept Post-Discharge Clinic

Concept Transitional Care

Concept Adverse Event

Concept Readmission

Concept Emergency Department Return

Distinguished Non-Finalist

Presenter Organization University of Chicago

Presenting Author Gilmer Rodriguez

Track Transitions of Care

Keywords

post-discharge clinic

transitional care

hospital discharge

readmission reduction

emergency department returns

care coordination

primary care follow-up

medication reconciliation

adverse events

patient navigation

Post-Discharge Clinic

Transitional Care

Adverse Event

Readmission

Emergency Department Return