University Health System (UHS) in San Antonio has created a space that gets patients out of beds, but keeps them on-site until they have the information or resources they need to go home (Figure 1). When UHS opened its trauma tower in spring 2015, the facility included a Transitional Care Center (DiNardo, 2016). The approximately 2,500-square-foot enclosed waiting area serves those who’ve been discharged but aren’t able to immediately walk out the door. It also aims to serve direct-admit patients for whom a bed is not yet available.
The care center’s design focused on patient input, customer service, and readmission reduction, explains Joyce Ornelas, MSN, MHA, RN, NE-BC, director of the UHS Transitional Care Center. “We also wanted to reduce throughput time so patients waiting for a bed had a shorter wait. We analyzed what was keeping patients in beds after their treatment was completed and tailored our services to meet those needs. We wanted to keep our customer satisfaction scores high and still effect quicker throughput times,” she says.
The goal was to create a comfortable place where patients could wait for prescriptions, durable medical equipment, a ride, or other needs. The care center is outfitted with a TV and recliners, as well as snacks, meals, and coffee. Perhaps most importantly, staff can review discharge information with patients as they wait.
“Many times when patients leave, so much information is presented to them that they need reinforcement of that education,” Ornelas points out. “The staff here can review upcoming appointments, medication instructions, etc. Staff also let the patients know that they can access their medical records and help patients sign up for that service online.” They also reinforce follow-up appointments, clinic phone numbers, and Nurse Link information to prepare the patient to handle problems at home and encourage further contact. Staff also help patients get their prescriptions filled.
“[Patients] tell us they appreciate the prescription services so they don’t have to find the pharmacy by themselves. If we help them with prescriptions and review those with the patient, they are more likely to be compliant with their medication regimen, and that can reduce readmissions,” Ornelas says. The center has been outfitted with a video conference monitor that allows patients to speak directly with the pharmacist, as well as a chute that transports prescriptions from the pharmacy.
UHS’ care center offers a gradual transition from the clinical environment where patients faced with taking charge of their care can get all of their questions answered. “Patients tell us they sometimes feel overwhelmed by everything that happens at discharge time, and they appreciate someone going over things with them again,” Ornelas says.
Adding clinics dedicated to discharge follow-up
An often cited contributor to hospital readmissions is a lack of appropriate follow-up care. Patients discharged to home are typically advised to contact their primary care physician, as those professionals are well positioned to answer questions, adjust medications, and address the conditions that landed the individual in the hospital in the first place. Yet a study from the Dartmouth Atlas Project found that only about 42% of hospitalized Medicare patients had contact with their primary care clinician in the two weeks following discharge (The Dartmouth Institute, 2011). For some patient populations, follow-up rates were significantly lower.
Today, more health systems are seeking to address this disconnect with post-discharge clinics. ECRI Institute’s 2015 Top 10 Hospital C-Suite Watch List describes these clinics as a setting designed to increase “patient access to post-hospital care through a primary care-based, hospitalist-staffed approach to transitional care” (ECRI Institute, 2015).