When patients go to the emergency room (ER) or are admitted to the hospital, their primary care providers may not find out until days or even weeks after the fact. By that time, a patient may have gone back to the ER or been readmitted to the hospital for reasons that could have been prevented by a prompt follow-up visit with their PCP.

To prevent unnecessary hospital visits and improve transitions of care, the Jackson Clinic (TJC), a multispecialty and primary care clinic in Jackson, Tenn., created a system in 2015 to ensure its providers were notified when patients went to the ER or were admitted to the hospital. TJC isn’t able to integrate its electronic health record (EHR) with that of the nearest hospital, Jackson-Madison County General, but that hasn’t prevented the clinic from effectively following up with patients. Instead, TJC leverages hospitalists to notify care coordinators of admissions. All care coordinators can access the hospital EHR and the clinic records simultaneously while working through the transition of care process.

The hospital generates a daily spreadsheet of all patients seen in the ER the previous day who identify with a Jackson Clinic primary care provider. The clinic wrote a script that converts this spreadsheet into an individual task for each patient on the list. Working from the task list, the clinic’s care coordinators reach out to each patient within 48 hours. During this initial phone call, they check on the patient’s progress since discharge, review medications and discharge instructions, arrange transportation, discuss any general health concerns, and schedule the patient to see his or her primary care provider. The goal is to connect every patient with primary care within seven days of discharge.

For each patient, the clinic calculates a LACE score, a standardized metric that predicts the risk of readmission based upon length of stay, acuity, chronic conditions and ER admissions in the past six months. A score greater than 10 indicates a high risk of readmission; any patient at or above 10 receives at least two more follow-up calls from a care coordinator at seven and 30 days past the follow-up PCP appointment.

“The No. 1 problem involves medication reconciliation,” said Sarah Johnson, Director of Population Health and Value-Based Contracting at the Jackson Clinic. “Sometimes the discharge medication list is correct, but the patient won’t take the meds until they talk to their PCP. If it’s a patient who has more than a few meds, that’s the biggest opportunity to improve the transition of care.”

The staff continues to prioritize medication reconciliation post-discharge and focus on patients with complex needs who are at risk for readmission. The clinic tracks readmission rates as its primary metric of success in transitions of care.

More recently, TJC has been measuring readmissions particularly among patients with a LACE score of more than 10. In 2018, 54% of patients flagged for Transitions of Care Management (TCM) were at high risk for readmission, but only 17% of those patients were readmitted. Their readmission rate for all TCM patients in 2018 was 16% and dropped even further in 2019.

If your practice is interested in learning more about helping your patients with transitions of care, please reach out to your network contact or email us at info@vhan.com.