Evaluation of an Innovative Transitional Care Clinic in an Interprofessional Teaching Practice

During transitions of care, great opportunity exists for miscommunication, poor care coordination, adverse events, medication errors and unnecessary healthcare utilization costing billions of dollars annually. An Interprofessional Transitions of Care (IPTC) clinic was developed utilizing a Family Medicine team that included physicians, nurses, a clinical social worker, and a clinical pharmacist. The purpose of this study was to determine if utilization of an IPTC clinic prevented hospital readmission, and to identify factors that predict most benefit from an interprofessional approach to transitions of care. A retrospective chart review of 1,001 patients was completed. A treatment group (TG) of 501 patients were offered IPTC clinic appointments following hospital discharge. A control group (CG) of 500 patients were hospitalized and received traditional follow-up prior to development of the IPTC clinic. Traditional follow-up typically consisted of an automated appointment reminder and a physician office visit. Outcomes assessed included 30-day hospital readmission of TG versus CG, and whether patient characteristics predisposed specific patient groups to attend IPTC appointments or benefit more from IPTC participation. Compared with CG, patients who completed an IPTC appointment were 48% less likely to be readmitted to the hospital within 30 days. Patients with congestive heart failure and cellulitis particularly benefited from IPTC. Telephone contact within two business days of discharge was the greatest predictor of patients attending an IPTC appointment. These results demonstrate that an interprofessional approach to transitions in care effectively addresses this high risk for error and high cost time in the continuum of care

Does a Single Item Alcohol Screening Test Improve Rates of Diagnosis/Referral of Alcohol Use Disorder in a Medicare Population with Diagnosis of Depression or Anxiety?

Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol use has been shown to reduce rates of alcohol use across multiple clinical settings, and is routinely recommended by the United States Preventative Services Task Force (USPSTF). In 2005 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended implementing a single item screening question (SISQ) for this purpose. Since then the SISQ has been well validated compared to other tools, such as the Alcohol Use Disorders Identification Test (AUDIT). It has not, however, been well studied in particular populations, such as those with comorbid anxiety and/or depressive disorders. Medicare Annual Wellness Visits present a unique opportunity to study the SISQ because while they do inquire about alcohol use, they do not routinely include a SISQ. Our study seeks to investigate the efficacy of implementation of a SISQ during Medicare Annual Wellness Visits in a residency clinic population with anxiety and/or depressive disorders. Data collection is ongoing and will measure rates of referral to treatment before and after the SISQ is implemented, as well as rates of brief interventions given

Interprofessional Transitional Care Teams Reduce Medications Needed Post-Discharge

Purpose: The United State health system is fractionated: most patients travel from location to location to see various clinicians about specific aspects of their health. The poor outcomes and high cost we currently see in the United States health system has challenged clinicians to explore better processes. This study sought to identify the potential impact of utilizing interprofessional transitional care (IPTC) teams in the primary care setting following hospitalization. One outcome measured was the relationship between pharmacist’s participation and number of medications a patient was taking after their IPTC visit. Electronic Health Records were utilized to extract patient data and it was analyzed using SPSS and R programming to examine relationships between patient populations, disease states, number of medications, and pharmacist intervention. This study was conducted as part of an overall investigation into benefits of IPTC teams in Primary Care. We expect that the number of the medications to be reduced for patients that had a pharmacist involved in their transitional care visit