Bridging the gap: a resident-led transitional care clinic to improve post hospital care in a safety-net academic community hospital

• Published in: BMJ open quality Vol. 13; no. 1; p. e002289
• Main Authors: Li, Patrick, Kang, Tiffany, Carrillo-Argueta, Sandy, Kassapidis, Vickie, Grohman, Rebecca, Martinez, Michael J, Sartori, Daniel J, Hayes, Rachael, Jervis, Ramiro, Moussa, Marwa
• Format: Journal Article
• Language: English
• Published: England British Medical Journal Publishing Group 19-03-2024; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Aftercare; Age; Clinics; Ethnicity; Gender; Health facilities; Heart failure; Hospitalists; Hospitals; Hospitals, Community; Humans; Implementation science; Indigent care; Language; Medicaid; Medical records; Medicare; Observational studies; Patient Discharge; Patients; Primary care; Quality improvement; Regression analysis; Safety-net Providers; Short Report; Transitional Care; Transitions in care; United States > US; Quality improvement; Implementation science; Transitions in care
• ISSN: 2399-6641; 2399-6641
• DOI: 10.1136/bmjoq-2023-002289

The transitional period between hospital discharge and primary care follow-up is a vulnerable time for patients that can result in adverse health outcomes and preventable hospital readmissions. This is especially true for patients of safety-net hospitals (SNHs) who often struggle to secure primary care access when leaving the hospital due to social, economic and cultural barriers. In this study, we describe a resident-led postdischarge clinic that serves patients discharged from NYU Langone Hospital—Brooklyn, an urban safety-net academic hospital. In our multivariable analysis, there was no statistical difference in the readmission rate between those who completed the transitional care management and those who did not (OR 1.32 (0.75–2.36), p=0.336), but there was a statistically significant increase in primary care provider (PCP) engagement (OR 0.53 (0.45–0.62), p<0.001). Overall, this study describes a postdischarge clinic model embedded in a resident clinic in an urban SNH that is associated with increased PCP engagement, but no reduction in 30-day hospital readmissions.