SHM Converge Scientific Abstract ePoster Gallery-Utilizing a Closed Loop Referral System to Transition Care

Pdf Summary

This poster describes Baylor St. Luke’s Medical Center’s use of Epic’s Care Everywhere Referral Management (CERM) to improve outpatient follow-up for hospitalized patients who need care at Baylor Medicine, despite the two systems not being integrated.<br /><br />Key points:<br />- BSLMC is an 850-bed referral center with about 26,000 admissions per year.<br />- Many discharged patients need specialty follow-up, but the hospital and outpatient practice use separate EMRs.<br />- In June 2019, new referral orders were built in Epic to send referrals through CERM to a centralized BCM referral center, which then scheduled follow-up visits.<br />- Appointment details were placed in the discharge after-visit summary.<br />- Providers were educated through emails, videos, and other tools to encourage use of the system.<br /><br />Outcomes tracked from June 2019 to February 2022 included monthly referral volume, the percentage of referrals scheduled, the percentage completed, and 30-day readmissions. The poster shows that referral volume increased over time, while scheduling and completion rates improved but remained incomplete. Common reasons for unscheduled referrals included inability to contact the patient, patient calling back later, telephone encounters sent to clinical staff, “do not schedule” status, patient decline, and insurance not being accepted.<br /><br />Readmission data suggested differences by appointment status:<br />- Completed appointments had a 14.23% 30-day readmission rate.<br />- No-shows had a 21.63% readmission rate.<br />- Canceled appointments had a 19.49% readmission rate.<br />- Unscheduled referrals had a 16.51% readmission rate.<br />- Overall readmission rate was 16.81%.<br /><br />Conclusion:<br />Epic CERM can help bridge care transitions between non-integrated systems and support closed-loop referrals, but sustained coordination and institutional commitment are needed to improve scheduling, completion, and follow-up outcomes.

Asset Subtitle

Neeraj Agrawal

Meta Tag

Author List Neeraj Agrawal

Category Research

Concept Epic Care Everywhere Referral Management

Concept Closed-Loop Referral Tracking

Concept Outpatient Subspecialty Follow-Up

Concept Ambulatory Referral Order

Concept Unscheduled Referral

Distinguished Non-Finalist

Presenter Organization Baylor College of Medicine

Presenting Author Neeraj Agrawal

Track Transitions of Care

Keywords

Epic Care Everywhere Referral Management

CERM

Baylor St. Luke’s Medical Center

Baylor Medicine

outpatient follow-up

closed-loop referrals

care transitions

hospital discharge

readmission rates

referral scheduling

Epic Care Everywhere Referral Management

Closed-Loop Referral Tracking

Outpatient Subspecialty Follow-Up

Ambulatory Referral Order

Unscheduled Referral