This practice aims to reinvent the care transition process for hospitalized patients to build more trust and continuity between patients and inpatient providers as well as to establish a safe transition to an outpatient network (either new or previously established). Many patients feel their clinical support network vanishes when they leave the hospital as there are often no reliable ways to contact the discharging medical team. Additionally, patients sometimes feel like inpatient providers abandon their responsibility to them once they leave the hospital.
With this practice, all patients discharged home are scheduled for a follow-up visit with the same physicians that cared for them during their hospitalization. If the patients have a telecapable device, they are enrolled in MyChart and scheduled for a virtual video visit. If they do not have a telecapable device, they are scheduled for a telephone call.
These virtual visits/calls occur within 2 days of discharge from the hospital. These do not take the place of their normally scheduled primary care provider follow up in 7-10 days after discharge.
Both the attending hospitalist and senior resident on the team hold these visits with their previously discharged patients on select days of the week. On the call, the providers assess for clinical symptoms, understanding of medications, and any issues with home services or medical equipment setup. A workflow for involving the appropriate team members to solve any identified problems has been established with the help of care management, social work, pharmacy, and the patient experience team.
Often the most challenging part of a patient’s hospitalization is the transition home. Utilizing the established rapport of patients with their inpatient providers, these visits make sure no issues arise during the transition.