Too Many Cooks in the Kitchen? Interdisciplinary Team Discharge Clinic Prevents Hospital Readmissions

Establishment of Interdisciplinary healthcare teams have shown to improve health outcomes and lower readmission rates in medically complex patients during hospitalization. Exploration of interventions has happened largely during the pre-discharge phase rather than post-discharge. To extend the team based approach, we implemented a pilot study of an interdisciplinary discharge clinic to determine what impact a biopsychosocial approach to care can have on hospital readmission rates. This work was conducted at a large family medicine residency-based practice, and facilitated by a physician, behavioral health clinicians, a clinical pharmacist, nurse care managers, and medical assistant. Patients were seen in the discharge clinic within 7 days of hospital discharge. In addition to patient demographics, data collected prior to visits included the calculation of a LACE score to identify risk of readmission, utilizing the BOOST (Better Outcomes for Older Adults Through Safe Transitions) risk assessment tool to identify high-risk medications. Additional data collected during the team visit included a CESD (Center for Epidemiologic Studies Depression Scale) score and MOCA (Montreal Cognitive Assessment) score to determine any psychosocial barriers to optimizing patient care; these standardized measures were conducted as part of a larger clinical interview. The total number of medications pre- and post-visit were collected along with the number of medication related problems identified following a comprehensive medication review. The primary outcome is the number of patients readmitted in 30 days. Secondary outcomes include average length of visits, total number of medications pre and post visit, number of medication related problems identified, existence of social support systems, and degree of patient satisfaction with the team visit. Future considerations include developing a sustainable, reproducible model for interdisciplinary discharge care that includes a component of inter-professional education

Reducing Hospital Readmission Through Team-Based Primary Care: A 7-Week Pilot Study Integrating Behavioral Health and Pharmacy

Introduction: A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings. Method: A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients’ mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot studywas conducted to determine the utility of the model. Results: Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success. Discussion: Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems’ costs. Recommendations for research in a clinical setting are also offered

Post-hospitalization discharge clinic: Who, What, When & Why?

We attempted to prevent hospital readmissions by creating a new, interdisciplinary discharge clinic at our urban, residency-based practice. Within a week of discharge, patients were scheduled by care management to meet with a team of clinicians, including a physician, psychologist, pharmacist, and nurse care manager within the same visit. During the visit, we discussed the hospitalization primarily from the patient’s point of view, including patient perceptions of care, readiness for discharge, and issues surrounding medication reconciliation in an attempt to come to a shared understanding of readmission risk. Patients were also screened for mental health disease that could impact care, including depression and cognitive disorders. The team worked collaboratively with each patient to enhance patient understanding of the hospitalization, including safety with medications, gaps in care, potential reasons for readmission, and next steps for the patient. We found that patients overwhelmingly enjoyed the visits if they could adapt to a team-based approach, and we were able to identify actionable items for each patient to advance their care in the outpatient setting.In this lecture we will present the specific content discussed in the visits, the rationale for this content in the post-discharge visit, and additional logistical workflows we created. Then we will present some of our preliminary findings from this work including the role of nonphysician leadership in the interdisciplinary team, potential for interprofessional education in the clinic, and where we hope to go next in doing this type of work in the field of hospital to medical home transition. Upon completion of this session, participants should be able to: Start their own interdisciplinary discharge clinic to address preventable hospital readmissions Value and maximize the role of non-physician leadership in the interdisciplinary team Integrate interprofessional education into the discharge clinic by utilizing medical residents, pharmacy students, and behavioral health trainees into the team-based settin

Post-hospitalization discharge clinic: Who, What, When & Why?

We attempted to prevent hospital readmissions by creating a new, interdisciplinary discharge clinic at our urban, residency-based practice. Within a week of discharge, patients were scheduled by care management to meet with a team of clinicians, including a physician, psychologist, pharmacist, and nurse care manager within the same visit. During the visit, we discussed the hospitalization primarily from the patient’s point of view, including patient perceptions of care, readiness for discharge, and issues surrounding medication reconciliation in an attempt to come to a shared understanding of readmission risk. Patients were also screened for mental health disease that could impact care, including depression and cognitive disorders. The team worked collaboratively with each patient to enhance patient understanding of the hospitalization, including safety with medications, gaps in care, potential reasons for readmission, and next steps for the patient. We found that patients overwhelmingly enjoyed the visits if they could adapt to a team-based approach, and we were able to identify actionable items for each patient to advance their care in the outpatient setting.In this lecture we will present the specific content discussed in the visits, the rationale for this content in the post-discharge visit, and additional logistical workflows we created. Then we will present some of our preliminary findings from this work including the role of nonphysician leadership in the interdisciplinary team, potential for interprofessional education in the clinic, and where we hope to go next in doing this type of work in the field of hospital to medical home transition. Upon completion of this session, participants should be able to: Start their own interdisciplinary discharge clinic to address preventable hospital readmissions Value and maximize the role of non-physician leadership in the interdisciplinary team Integrate interprofessional education into the discharge clinic by utilizing medical residents, pharmacy students, and behavioral health trainees into the team-based settin

Too Many Cooks in the Kitchen? Interdisciplinary Team Discharge Clinic Prevents Hospital Readmissions

Establishment of Interdisciplinary healthcare teams have shown to improve health outcomes and lower readmission rates in medically complex patients during hospitalization. Exploration of interventions has happened largely during the pre-discharge phase rather than post-discharge. To extend the team based approach, we implemented a pilot study of an interdisciplinary discharge clinic to determine what impact a biopsychosocial approach to care can have on hospital readmission rates. This work was conducted at a large family medicine residency-based practice, and facilitated by a physician, behavioral health clinicians, a clinical pharmacist, nurse care managers, and medical assistant. Patients were seen in the discharge clinic within 7 days of hospital discharge. In addition to patient demographics, data collected prior to visits included the calculation of a LACE score to identify risk of readmission, utilizing the BOOST (Better Outcomes for Older Adults Through Safe Transitions) risk assessment tool to identify high-risk medications. Additional data collected during the team visit included a CESD (Center for Epidemiologic Studies Depression Scale) score and MOCA (Montreal Cognitive Assessment) score to determine any psychosocial barriers to optimizing patient care; these standardized measures were conducted as part of a larger clinical interview. The total number of medications pre- and post-visit were collected along with the number of medication related problems identified following a comprehensive medication review. The primary outcome is the number of patients readmitted in 30 days. Secondary outcomes include average length of visits, total number of medications pre and post visit, number of medication related problems identified, existence of social support systems, and degree of patient satisfaction with the team visit. Future considerations include developing a sustainable, reproducible model for interdisciplinary discharge care that includes a component of inter-professional education