SHM Converge Scientific Abstract ePoster Gallery-Virtual Transitions of Care (Vtoc) Pilot Study: Closing the Gap Between Inpatient and Outpatient Settings

Pdf Summary

The Virtual Transitions of Care (VToC) pilot studied whether hospitalist-led video visits could improve post-discharge care for high-risk medicine patients at UC San Diego Health. Patients were eligible if they were discharged from the Medicine service, had a LACE score of 50 or higher, and had a UCSD primary care provider. Between November 2020 and March 2021, 78 patients completed virtual visits within 96 hours of discharge.<br /><br />During these visits, hospitalists focused on reviewing test results, reconciling medications, reassessing symptoms, and counseling patients. They also sent electronic handoffs to primary care and subspecialty clinicians to support follow-up planning. The most common intervention was expediting care with primary care or specialists, followed by medication reconciliation and counseling. On average, each visit resulted in about three medication changes.<br /><br />The pilot showed strong feasibility and engagement: all visits occurred within the target time window, and 57.5% of patients completed a PCP visit within 30 days, compared with a 9.3% benchmark. Readmission rates were lower than benchmark rates for patients with LACE scores of 50–65, though results varied in higher-risk groups.<br /><br />Most participating hospitalists reported that the program positively influenced their inpatient discharge practices. Overall, the study suggests that a virtual transitions clinic may improve medication management, support timely outpatient follow-up, and help triage specialty care after discharge. However, the authors note limitations including the small sample size and possible selection bias. Further study is needed to determine how VToC affects readmissions across different patient populations.

Asset Subtitle

Sarah Horman

Meta Tag

Author List Daniel Bouland, Diana Childers, John Bell, Milla Kviatkovsky, Sarah F. Horman, Sarah Horman, Talya Bordin-Wosk, Yan Xing

Category Innovations

Concept Virtual Transitions of Care Clinic

Concept Post-Discharge Support

Concept Care Transition

Concept Patient Referral Criteria

Concept LACE

Distinguished Non-Finalist

Presenter Organization UC San Diego Health

Presenting Author Sarah Horman

Track Transitions of Care

Keywords

Virtual Transitions of Care

VToC pilot

hospitalist-led video visits

post-discharge care

medicine patients

medication reconciliation

primary care follow-up

readmission rates

UC San Diego Health

LACE score

Virtual Transitions of Care Clinic

Post-Discharge Support

Care Transition

Patient Referral Criteria

LACE