Care transitons is a critical focus in cost containment.  

 

We propose an email-based discharge communication process to identify multidisciplinary needs on admission of an inpatient, and communicate these simultaneously to multiple multidisciplinary providers in the primary care medical home and ancillary clinics.  Purpose to improve multidisciplinary discussion and planning for patients beginning at admission to allow leadtime for ensuring appointments, fostering discussion between inpatient and outpatient providers, educating and engaging the patient in the plan.

 

The process implementation involves 2 steps:

(1) creation of a combined communication and screening tool to address complex, multidisciplinary needs, using the existing evidence base for care transitions tools

(2) coordination with outpatient PCMH's and specialty clinics to meet self-identified needs in the process of inpt to outpatient transition

 

While this proposal is email-based, it could be easily adapted to eCW, EPIC, or another communication tool or EHR platform.

 

The process involves templated communication on admission and discharge to be sent to the patient's: 

- PCP

- PCMH clerk 

1) basic information on admitting dx, admission date, expected dc date

2) patient results on a simplified screening tool for multidisciplinary needs (eg. behavioral health f/u, pharmacy medicine reconciliation f/u, HF or COPD specialty clinic f/u, etc.)

3) contact information and instructions for outpatient providers to contact inpatient providers

4) routing list specified to each outpatient clinic's provider resources

 

The process expected outcomes:

1) scheduled follow-up appt information for inpatient team to provide to patient prior to dc

2) arrangement of ancillary f/u appts (behavioral, pharmacy, etc.)

3) communication of admission details to all pertinent outpatient providers in multiple disciplines

4) opportunity for asynchronous communication for all care providers for a given patient beginning on admission to better coordinate care without interrupting clinical workflow (primary care clinic visits, inpatient, etc.)

 

The concept leverages an inexpensive, efficient communication strategy (email), incorporates standards (timeliness, utility of information without extraneous detail) with adaptability to future platforms, and ultimately may improve coordination of care and ideally patient outcomes. It also allows each PCMH to use their own internal workflow, while still allowing for a standardized approach from the inpatient setting.