2022 Stronger - PH365 - Bridge Clinic Approaches that Improve Care Transitions and Reduces Readmissions
This session features a diverse panel of health care leaders who will share their experiences and successful methods to bridge the patient experience, transitioning from acute care to the post-acute care environment.
UC San Diego Health implemented a post-discharge virtual transitions of care clinic (VToC) that reduced 30-day all-cause readmissions. The period immediately after discharge is overwhelming for patients, leaving them vulnerable to poor experiences and outcomes. The VToC bridges the chasm caused by care silos, communication lapses and social determinants of health (SDoH). Additionally, observations from this clinic shed light on systemic inefficiencies to inform broader organizational quality improvement around increasing transitional care reliability.
Temple University Hospital developed a “bridge clinic” that manages patients through multidisciplinary transitional care that utilizes community health workers who partner with clinicians to provide close post-discharge engagement and follow-up. This community health worker-driven transitional clinic addresses SDoH needs through interventions like the provision of transportation, fresh food, patient health education and social worker access. The clinic has demonstrated higher than average clinic show rates and decreased 90-day all-cause ED visits and readmissions after participation. Relationships with patients across the continuum of health care can be a key method in improving health literacy, patient engagement and patient outcomes. This approach serves as a cost-effective model to prevent readmissions.
Join this panel to learn and discuss ideas for successful care transitions.
- Healthcare Quality Professionals
- Other Healthcare Professionals
- Discuss the role of a transitions clinic in identifying systemic care lapses to inform broader quality initiatives.
- Describe how to care for patients across the continuum of care from inpatient to outpatient and, specifically, how to prevent readmissions in an urban area with high socioeconomic barriers.
Sarah Horman, MD, Hospitalist, Medical Director, Virtual Transitions of Care Clinic, UC San Diego Health, San Diego, CA
Eric Lundin, Project Manager & Organizational Consultant, UC San Diego Health, San Diego, CA
Claire Raab, MD, Chief Executive Officer, Temple Faculty Practice, Temple University Hospital, Philadelphia, PA
Dharmini Shah Pandya, MD, Medical Director, MVP Clinic, Associate Program Director, Internal Medicine Residency, Temple University Hospital, Philadelphia, PA
Steven R. Carson, MHA, BSN, RN, Senior Vice President Population Health, Temple University Hospital, Philadelphia, PA
Interprofessional Continuing Education (IPCE)
This activity was planned by, and for, the healthcare team, and learners will receive 0.75 Interprofessional Continuing Education (IPCE) credits for learning and change.
Vizient, Inc. designates this live activity for a maximum of 0.75 ANCC contacts hours.
Vizient, Inc. designates this live activity for a maximum of 0.75 contact hours for Pharmacists.
Universal Activity Number: JA0006103-0000-22-176-L04-P
Vizient, Inc. designates this live activity for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Healthcare Quality Professionals (CPHQ)
This activity is approved by NAHQ® for 0.75 CPHQ CE credits.
Other Healthcare Professionals (General CE Credit)
Vizient, Inc. will award a maximum of 0.75 contact hours to all other healthcare professionals who successfully complete the activity. These individuals will receive a Certificate of Participation indicating the maximum credits available.
Many state licensing boards and credentialing bodies accept certificates of participation from accredited CE activities to meet CE requirements for license renewals and re-certification. It is the responsibility of the participant to contact their state licensing board and/or certifying body for verification on credit eligibility reciprocity.
- 0.75 ACHE
- 0.75 ACPE Pharmacist
- 0.75 AMA PRA Category 1 Credit™
- 0.75 ANCC
- 0.75 CPHQ – Certified Professional Healthcare Quality
- 0.75 General CE – Attendance
- 0.75 New Interprofessional Continuing Education (IPCE)