Examples cited in the ECRI report include the Bridge Clinic of San Francisco General Hospital, where patients are set up with an appointment and contact information for the post-discharge clinic prior to leaving the hospital. At that appointment, the clinician might review medication use, help refill prescriptions, discuss last-minute test results, and ensure care is on track. The clinician also provides further patient education, encouraging self-diagnosis. And at Beth Israel Deaconess Medical Center in Boston, a computer algorithm identifies patients who have not listed a primary care physician or who can’t make a follow-up appointment with their primary care physician within two weeks of discharge, automatically referring those patients to Beth Israel’s post-discharge clinic.
“Many more of these clinics and care models have emerged,” notes Diane Robertson, director of ECRI Institute’s health technology assessment information services. She adds, “They take a lot of different forms—some systems set up clinics, others just have a person dedicated to the post-discharge care in the facility setting. Sometimes they have the patient come back to the actual clinic for their follow-up visit. Other times they’ll use that transitional care person to set up appointments with a primary care physician out in the community to ensure that patient has that first follow-up appointment.”