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.