SHM Converge Scientific Abstract ePoster Gallery-Use of Emr-Integrated Appointment Requests to Improve Post-Hospitalization Follow Up

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Northwell Health, New York State’s largest health care provider and private employer, focuses on high-quality care, education, research, and community service across 23 hospitals and more than 700 outpatient sites.  <br /><br />This project aimed to improve post-hospitalization follow-up by using the electronic medical record (EMR) to automatically send appointment requests to a dedicated patient access team for discharged medicine patients with a home disposition. The goal was to make timely outpatient appointments more reliably, since follow-up after hospitalization is important for reducing readmissions and improving outcomes, but is often missed because clinical teams are busy.<br /><br />At the first pilot site, an 800-bed quaternary hospital, the workflow generated 12,390 referral requests from March 2022 to January 2023, resulting in 7,135 scheduled appointments, a 57.6% success rate among completed referrals. A major challenge was reaching patients by phone after discharge, so the team added an on-site referral coordinator to engage patients before they left the hospital. The process was then expanded to a second 600-bed hospital, focusing on Medicare patients; from August 2022 to January 2023, 278 of 475 requests resulted in appointments, a 58% success rate.<br /><br />The intervention showed promising downstream impact. At the original pilot site, Medicare readmissions decreased year over year from 16.7% in 2021 to 14.9% in 2022 for the March–December period. The project suggests that using nonclinical staff and existing workflows to schedule follow-up appointments can reduce clinician burden, support medication reconciliation, and potentially improve readmission rates. The approach appears scalable across a large health system and is being further refined.

Asset Subtitle

Jonathan Silver

Meta Tag

Author List Giovanna Deleon, Jaclyn Kelly, Jonathan Silver, Michele Pirog, Oluwaseun Adeosun

Category Innovations

Concept Outpatient Follow-up

Concept Transitional Care

Concept Readmission

Concept Discharge Appointment

Concept Post-Discharge Scheduling

Distinguished Non-Finalist

Presenter Organization North Shore University Hospital, Northwell Health

Presenting Author Jonathan Silver

Track Transitions of Care

Keywords

Northwell Health

post-hospitalization follow-up

electronic medical record

appointment scheduling

patient access team

discharged medicine patients

readmission reduction

care coordination

Medicare patients

outpatient appointments

Outpatient Follow-up

Transitional Care

Readmission

Discharge Appointment

Post-Discharge Scheduling