Problem
Transitional care interventions are essential to reduce readmissions.(1) Unfortunately, post-discharge follow-up appointments often are scheduled without the patient’s input during hospitalization.(2) Furthermore, arranging appointments with primary care providers (PCPs) for patients can be challenging because of the demand from other patients on their PCPs’ panels. To address these challenges, our objective was to provide patients with a choice of transitional care appointment while implementing a concierge-type appointment at the time of the appointment date.
Purpose Statement
The aim of this study was to evaluate the efficacy of arranging post-discharge appointments on the preferred date of the patient and the impact of flexible scheduling on the completion rates and no-show rates for follow-up transitional care. We hypothesized that scheduling appointments on the patient’s preferred date would decrease the no-show rate, and that flexible scheduling would result in improved outcomes.
Innovation
A comprehensive plan was developed to establish a post-discharge clinic (PDC) aimed at bridging the quality gap present in the institution by creating transitional care processes that would increase transitional care access to PCPs and decrease readmissions.(3,4) The scheduling of these processes is of paramount importance, because that determines when, where, and how patient transitional care will be delivered, as well as the anticipated outcomes of these interventions. Our goal was to create a streamlined and user-friendly process for referral providers, a concierge-style service for our patients, and robust communication channels with patients’ primary care physicians.
During a 14-month period we designed and implemented various operating scheduling models and evaluated their effectiveness in terms of capacity, booked appointments, completed appointments, and no-show rates. We also assessed the impact of staffing models based on networking and the diversion of institutional resources to support the PDC. To achieve our vision, we have taken three critical steps:
Our institutional systems utilize patient navigator coordinators (PNCs) to arrange appointments with PCPs through central scheduling. However, we found this process to be unfriendly for patients who did not have the opportunity to select their preferred date for appointments, which impacted ambulatory dashboards and revenue. To address this issue, we developed EPIC interventions that allow PNCs to access and schedule appointments directly on the PDC providers’ schedules.(5,6) We strongly encourage PNCs to share the date and time of appointment availability with patients.
In addition, a PDC nurse monitors the clinic schedule and maintains close contact with patients to ensure their availability for PDC appointments.
Lastly, we have implemented flexible scheduling, which allows us to adjust appointment times to the patient and family’s preferences or switch to video visits, according to the patient’s choice.
Outcomes
The evaluation of outcomes was guided by ambulatory care dashboards and PDC scorecards. The interventions demonstrated a pattern of appropriate referrals being implemented, a reduction in the no-show rate, and an increase in the timely cancellation of appointments, resulting in enhanced availability of transitional appointments.
Between July 2023 and June 2024, significant improvement trends were observed post-hospitalization compared with the previous year; moreover, access continued to improve over the last two months of this academic year. The current access within 14 days for a PDC appointment is 98.1%, with an average appointment wait time of 7.7 days.
The number of completed appointments decreased from the previous academic year, which can be attributed to the proficiency of the PNCs in scheduling PCP appointments within 14 days post-hospitalization and the establishment of new PCP clinics in the surrounding regions. However, completed appointments continued to increase for the last two months of this academic year, with the majority of appointments being delivered in-person.
The no-show rate was significantly reduced from the previous academic year, while the number of patient cancellations increased. This achievement can be attributed to the hiring of a PDC nurse who provides post-hospitalization calls to patients before their PDC appointments and cancels appointments for patients who are unable to attend a PDC appointment.
Visits were modified to in-person consultations, which facilitated close monitoring of patients with a high risk of readmissions, provided patients and providers with the option to select their appointment type, and allowed providers to indicate their preferences for referrals.
Table 1 presents the performance metrics for the PDC visitation, based on data from the University of Chicago Medicine Ambulatory Care appointment dashboard. The performance metrics include access, the number of completed visits, the no-show rate, the cancellation rate, and the type of visits.
Takeaways
Our findings were as follows:
Initially, no financial resources were allocated for the launch of the PDC. As a result, our focus shifted to building relationships with key leadership figures and understanding the internal resources that were available within the organization.
The role of PNCs was essential in helping patients schedule appointments at the PDC on their preferred date and time.
A PDC nurse with experience in inpatient care and management played a crucial part in implementing a flexible schedule, making transition care calls when the Population Health nurse was not available and contacting patients to cancel appointments early, confirm desired date and time, and minimize no-shows. (Regrettably, we were unable to hire a part-time nurse until this year because of budgetary constraints.)
Keys to Innovation
Our study revealed the following key steps to instituting this innovation:
To promote this innovation, it is important to assess the transitional care capabilities of PCPs within your organization and how your initiative can enhance their patients’ access to care, ultimately reducing readmissions.
It is advisable to provide mentorship and close supervision of processes, outcomes, and Plan-Do-Study-Act cycles, which may require a significant time commitment.
Staffing the PDC with a dedicated nurse is a critical aspect of the program’s success, and it is important to demonstrate the cost-effectiveness of your program through data.
It is also crucial to prepare your organization for change. Look for opportunities for process innovation and take the time to research and plan for future innovation.
References
Coppa K, Kim EJ, Oppenheim MI, et al. Examination of post-discharge follow-up appointment status and 30-day readmission. J Gen Intern Med. 2021;36:1214-1221. https://doi.org/10.1007/s11606-020-06569-5
Berger R, Yang S, Weiner J, et al. Measuring patient preferences and clinic follow-up utilizing an embedded discharge appointment scheduler: a pilot study. Jt Comm J Qual Patient Saf. 2019;45:580-585. https://doi.org/10.1016/j.jcjq.2019.05.007
Rodriguez G, Meltzer D, Rodriguez L, Lewis V, Chen M. Telehealth and transitional care: reducing readmissions, emergency return visits and improving primary care access with limited budget. Healthcare Administration Leadership & Management Journal. 2024;2(3):110-114. https://doi.org/10.55834/halmj.4382918519 .
Rodriguez G, Meltzer D, Rodriguez L, Lewis V, Krishnamurthy R. Post-acute care: advancing population health interventions, risk assessment, and implications for readmissions and cost-effectiveness through telehealth. Telemedicine Reports. 2024;5(1):158-164. https://doi.org/10.1089/tmr.2024.0019 .
Luckett R, Pena N, Vitonis A, et al. Effects of patient navigator on no-show rates at an academic referral colposcopy clinic. J Womens Health. 2015;24:608-615. https://doi.org/10.1089/jwh.2014.5111
Krippel HY. Impact of Advance Access Scheduling on Missed Appointment Rates in Primary Care. Walden Dissertations and Doctoral Studies. 2020. https://scholarworks.waldenu.edu/dissertations/8304