Implementing Posthospital Interprofessional Care Team Visits to Improve Care Transitions and Decrease Hospital Readmission Rates.

Purpose/objectives: Today's health care climate is composed of patients who experience complex conditions with multiple comorbidities, requiring higher utilization of acute care services. It is imperative for acute care and primary care landscapes to bridge silos and form collaborative relationships to ensure safe and effective transitions of care from hospital to home. An interprofessional, posthospital follow-up clinic (Discharge Clinic) is one approach that can be used to improve transitions of care and decrease preventable hospital readmissions. The purpose of the Discharge Clinic is to improve transitions of care and decrease 30-day hospital readmission rates. The clinic's objective is to utilize an interprofessional care team to improve transitions of care posthospital, for complex care patients.

Primary Practice Setting: The posthospital Discharge Clinic is an innovative, interprofessional clinic located in a large western state that was initiated to improve transitions of care for its patients discharged from an acute care setting. The interprofessional care team consists of a certified family nurse practitioner, a clinical pharmacist, a nurse case manager, and a social worker.

Findings/conclusions: In 2013, Medicare and private coverage data reveal 30-day readmission rates of 17.3% and 8.6%, respectively (). From February 2016 to September 2016, Discharge Clinic project participants achieved a 30-day readmission rate of 2.7%. The Discharge Clinic enrolled 75 patients in the project (n = 75). The 30-day readmission rate achieved by the Discharge Clinic represents a significant decrease compared with national benchmark data. Two patients enrolled in the project were readmitted within 30 days of hospital discharge. For fiscal year 2015, the medical group's estimated cost of readmissions was $7,156,800 and 30-day all-cause readmission rate was 12.3%. This equated to the Discharge Clinic's estimated impact in reducing readmissions at 9.63% and an estimated savings of $689,199.84. The Discharge Clinic estimated its operating costs at $354,000, which gave a total estimated net savings of $335,199.84.

Implications For Case Management Practice: The current health care landscape is composed of an aging population, rising in complexity. New approaches are needed to bridge gaps between acute care and primary care settings. The Discharge Clinic serves as an innovative model that health systems throughout the country can replicate to improve transitions of care for complex patients. The interprofessional care team model can be implemented to advance and bridge the management of acute and ambulatory care patient populations.