PP06 – Heigh Ho! Heigh Ho! Off to the Doctor We Go
We will share a successful project that was piloted at South Pointe Hospital related to discharge follow up appointments.
At South Pointe hospital when a patient was being discharged there was inconsistency with the follow up appointments being made.
The appointments were attempted to be made by HUC’s (Health Unit Coordinators) or the patient was instructed to schedule their own appointment after discharge as it was stated on their after visit summary paperwork.
Appointments were being made inconsistent and without patient preference.
Patients often did not follow through with scheduling their own appointments or they were not aware that they needed to make a follow appointment.
SPH and the new Care Management Resource Center (CMRC) collaborated on a pilot to work together to ensure that all patients were getting a PCP and/or a Specialty appointment with 7-14 days after hospital discharge.
The inpatient transitional care coordinators (TCC’s) will gather all the information related to the appointment (PCP/Specialty, time frame, patient preference, etc.) then task the information to the CMRC for them to make the appointment. The patient then leaves the hospital with a follow up appointment they are aware of and agreed to.
At hospital discharge our goal was to increase the number of patients who are scheduled for clinically appropriate follow up appointments with 7-14 days to 100%.
At conclusion of the South Pointe pilot we had 1,434 total confirmed post hospital appointments with PCP’s, specialists and chronic care clinics.
After the pilot program, South Pointe continued post hospital appointments with an increase of scheduled appointments to 5536.
This process has implication in reducing 30 day readmissions and as a result of this success Cleveland Clinic has rolled out this initiative to the enterprise.