ACTion: An interdisciplinary approach to outpatient-based transitions of care

Purpose: To create an interdisciplinary team-based process of care through a post-hospitalization appointment set called complex-return-continuity (CRC).  Primary outcomes include reduced rehospitalizations and modeling an effective interdisciplinary team that facilitates medication reconciliation, coordination of care, communication, and patient activation which are key principles of a Patient Centered Medical Home (PCMH).

Methods: We followed the principles of the Model For Improvement by identifying an interdisciplinary team focused on reducing rehospitalizations.  We used Plan, Do, Study, Act cycles to test changes with predefined metrics to ensure that change led to improvement.   Initial process measures included detailed appointment cycle time, efficiency of CRC appointment use, patient and provider satisfaction.  

Results: Process improvements include successfully linking the CRC appointment with a pharmacist and a physician within our scheduling system, involving department scheduler and coordinating with the inpatient team.  This led to 36 scheduled CRC appointments with a no-show rate of 22.2%.  The readmission rate for no-show vs. those attended was 27.3% vs. 16.7% respectively.  Average cycle time was 90.08 minutes for CRC vs. 66.96 minutes for usual appointments however the majority of patients perceived the CRC appointment as the same duration as the usual appointment.  Most patients and providers perceived that patients had an improved understanding of their medications.

Conclusion: Using principles of quality improvement we demonstrated the feasibility of an innovative interdisciplinary appointment focused on transitions of care in an outpatient primary care practice. This included collaboration of physicians, pharmacists, care managers and their learners.  CRC appointments demonstrated a positive experience for patients and clinicians, an improvement in patient’s and physician’s understanding of patient’s medications, and a process for measuring efficiency of hospital follow-up and readmissions.  Future opportunities exist in modeling effective PCMH principles of team-based care to learners, improving utilization metrics in readmission rates, clinical outcomes and appropriate medication use.