UNC clinic slashes 30-day readmissions by 65%

The University of North Carolina Internal Medicine Clinic reduced its 30-day readmissions by approximately 65 percent by implementing a care-based follow-up program.

Key components of the program included real-time care management, improved access to care and content standardization in a multidisciplinary visit, according to a study on the intervention published in the Journal of General Internal Medicine.

As part of the intervention, clinic-based care managers were responsible for identifying discharged patients, risk-based triaging, scheduling appointments and working with patients to ensure transportation. Also, once discharged, patients were seen by a clinical pharmacist practitioner, who coordinated 60-minute appointments and by an attending physician for a 20-minute appointment.

The focus of the clinical pharmacist practitioner entailed working with the patient to achieve medication adherence goals. The physician performed a physical exam, diagnosed new problems, addressed goals of care and assisted with patient education, according to the study.

To refine the model for improvement, a patient intake questionnaire and note template were developed, which reinforced need for reminder phone calls. The researchers developed charts to measure the program’s progress, including quantity of hospital discharges, time to follow-up in the clinic and number of completed hospital follow-up visits.

“This study suggests that attention to primary care practice structure in the transition from inpatient to outpatient settings can reduce the rate of readmissions. This approach takes advantage of the relationship between the patient and the primary care home and may facilitate a more efficient and effective model of care,” the authors concluded.

View the full study here.