Transitions of Care Clinic featured in UF Health Managed Care Newsletter

CHP faculty member Stephanie Smith is a vital member of the team, which strives to reduce the 30-day hospital readmission rate.

The UF Health Managed Care newsletter has put a spotlight on the work of the Transitions of Care clinic.  The full issue is linked here.  The article is reproduced below. We congratulate Dr. Smith and her colleagues on this recognition.

“Population Health Management Initiatives:

SPOTLIGHT: TRANSITIONS OF CARE CLINIC

—Cindy Hare, RN, Population Care Manager

We are spotlighting a series of Best Practices used in our clinics. These programs are unique to each practice and have been developed to address the needs of a specific population. The first in our series features the Internal Medicine practice group at Medical Plaza. The Internal Medicine group at Medical Plaza began a new initiative called the Transitions of Care Clinic this year to address patients who have been hospitalized. Every patient that has been in the hospital the week prior is scheduled to be seen during this weekly clinic. One of the unique aspects of this clinic is that it is staffed not only by the physician and office staff, but by an interdisciplinary team, including Ryan Nall, MD; Melanie Hagen, MD, FACP; Maryann Grottano, RN, BSN, health coach; Katherine Vogel Anderson, Pharm.D., BCACP; Stephanie G. Smith, Ph.D.; Lee Collopy, LCSW; Tiffany Phillips, MSW, RCSWI; and Andrew Courtney, Homecare business development representative. In addition, residents, medical students, physician assistant students, and pharmacy students rotate participation regularly. The process of this clinic is also unique. Before the clinic begins, a pre-clinic team huddle is held to discuss the needs of the patients and the plan for the visit. I had the pleasure of sitting in on one of the team huddles and watched this team in action. Everyone participated, discussed individual patients and the needs they presented as well as the approach they would use to best assist the patient and address individual needs. This clinic is very focused on the individual patient and optimizing the plan of care.

In addition, I was able to interview Drs. Nall and Hagen, and Katherine Vogel Anderson, Pharm.D., BCACP, to ask questions about this clinic:

1.) How was this clinic started?
With a growing focus nationally on reducing hospital readmissions Internal Medicine at Medical Plaza and Tower Hill began to focus on what could be done in our clinic to reduce hospital readmissions and improve the transition of care between the hospital and clinic. Initially, an interdisciplinary group reviewed approximately half of the clinic’s 30-day readmissions from the year prior to determine common trends. We noted that many patients did not have timely followup appointments with our clinic following hospital discharge. We developed the transition clinic to help improve timely access for our patient.

2.) What were the thoughts that led to its creation?
To follow-up with primary care to reconcile medications and follow-up on symptoms and testing from hospitalization as well as to address psychosocial needs that might help to prevent readmissions.

3.) Why did you choose to use an interdisciplinary approach vs. physician follow-up alone?
When we reviewed the clinic’s 30-day hospital readmissions we realized that the patients being readmitted weren’t only medically complex, but were also extremely complex from a psychosocial perspective. Very often the issues leading to readmission weren’t being prescribed the correct antibiotic or antihypertensive, but rather having transportation to follow-up, home care services to help monitor symptoms, understanding which medications to take after discharge, reviewing a low salt diet, or treatment of the patient’s underlying depression and anxiety. The interdisciplinary team is critical to rapidly and effectively addressing these issues. Each member of the team brings a skill set that is invaluable and allows us to take fantastic care of our patients. Currently, our team consists of a registered nurse, pharmacist, social worker, home health representative, psychologist, physician, medical resident, medical student, pharmacy students, and physician assistant student. Seeing patients as a team is far more rewarding than seeing patients alone.

4.) Is this model based on research?
The clinic isn’t modeled after another clinic specifically. That being said, many models aimed at reducing readmissions utilize interdisciplinary teams to improve the transition of care and reduce readmissions.

5.) Are you conducting any research on the outcomes for the patients?
Now that the clinic has been active for six months, we will be evaluating its effectiveness.
In other words, does the clinic actually reduce readmission and ED utilization for the patients it serves? We will also be reviewing how the interdisciplinary nature of the clinic impacts work satisfaction and burnout.

6.) Do you feel that the patients that come to this clinic are better served because of the care they receive?
I certainly can’t speak for all clinics and physicians, but I do feel this interdisciplinary clinic provides better care to this cohort of psychosocially complex patients than an individual physician can alone. Social workers are far better at figuring transportation and coverage issues, pharmacists are much better at identifying drug-related problems and access to medications, nurses are able to spend a longer period of time educating on dietary restrictions, the home care representatives can set-up much needed services at home, the psychologist can begin to help the patient develop better coping strategies, and the list goes on and on. Each of us playing to our strengths as a team provides better care than any of us individually.

7.) What is the benefit of seeing the patients within one week of discharge?
The data supporting a specific time frame to see a patient after discharge to prevent readmission is spotty, but we generally believe that the faster we can connect with the patient in the outpatient clinic and identify any problems the better. All our patients receive a phone call by a registered nurse or pharmacist within 48 hours of discharge to make sure a follow-up appointment has been scheduled within the appropriate time frame, review medication changes, and identify any ongoing issues or new symptoms. CMS has also developed billing codes for Transitional Care Management (TCM) which can be utilized if the patient receives contact from the clinic in the first 48 hours after discharge and follow-up within 14 days for moderate complexity and 7 days for high complexity.

8.) Who within the organization has supported your plan?
Our group has been supported across the board by clinic and department leadership. Without their support this wouldn’t have been possible.

9.) How do you think the replication of this model could benefit the community we serve?
We will be able to answer this question better in the next month after our review has been completed. Personally, I can say working in an interdisciplinary team has been so much fun and fantastic for job satisfaction.

10.) Are you presenting this at a conference?
We hope to present this model at the upcoming Primary Care Innovations Conference at UF on March 10th. The conference is bringing together teams from the southeast who are innovating in primary care with the hopes of sharing and learning from each other to improve the care we provide our patients. The conference is open to anyone and everyone working to improve primary care. –Ryan Nall, MD

This program is an example of innovations that are happening here at UF Health to address the ever changing needs of our population. It is a shining example of our vision and values as an organization.”