Continuity of Care – Fragmentation of the Healthcare System
Continuity of care correlates with reduced hospital admissions and emergency department visits, leading to cost savings.
| Managing care among multiple providers
· Schedule follow-up appointments prior to discharge. · Communicate action items in writing. · Include all follow-ups in discharge paperwork. |
Living in a rural or underserved area?
· Evaluate whether the patient must return to the hospital for specialty care that is not available locally. · Determine whether follow-up can occur closer to home or virtually. |
| Various EMRs and information barriers
· Provide a printed copy of the discharge summary. · Ensure the patient has copies of all critical results. |
Insurance coverage
· Proactively verify network status for all referrals. · Ensure outpatient providers accept the patient’s insurance. |
Continuity of Care – Patient and Provider
Continuity of care correlates with reduced hospital admissions and emergency department visits, leading to cost savings.
| Patient-specific factors for appointments
· Does the patient have a PCP? Notify the PCP of admission/discharge; arrange follow-up 7-14 days after discharge. · Comorbidities: ESRD (consider non-HD days); cognitive status and caregiver availability. |
Communication with PCP
· At discharge, convey: conclusive diagnosis; medication changes; pending lab results; serial imaging requiring follow-up. · When discharging to SNF/SAR, a warm handoff to the facility provider is preferred. |
| Follow-up appointments
· SAR/SNF: specialists are covered and the rehab provider fulfills the PCP role. · Is the appointment at the clinic closest to the patient’s home? · Is transportation an issue? · Are scheduled appointments soon enough? |
Home care and services
· Home PT/OT · Outpatient PT/OT · Nursing · Line care · Wound care · Home Health Aide (HHA) |
References:
- Riverin BD et al. Optimal Timing of Physician Visits after Hospital Discharge to Reduce Readmission. Health Serv Res. 2018;53(6):4682-4703. doi:10.1111/1475-6773.12976. PMID: 2918 May 15. PMCID: PMC6232431.
- Kojima N et al. Cohort design to assess the association between post-hospital primary care physician follow-up visits and hospital readmissions. Medicine (Baltimore). 2022 Nov 18;101(46):e31830. doi:10.1097/MD.0000000000031830. PMCID: PMC9678564.
- Kripalani S et al. Reducing hospital readmissions: current strategies and future directions. Annu Rev Med. 2014;65:471-85. doi:10.1146/annurev-med-022613-090415. Epub 2013 Oct 21. PMID: 24160939; PMCID: PMC4104507.
Developed by Joshua Hirsch, Madeleine Reznik & Vasundhara Singh (Icahn School of Medicine at Mount Sinai) and Sonia Dalal (Johns Hopkins School of Medicine)
