KINGSPORT (Feb. 7, 2017) – The unique efforts of East Tennessee State University faculty, staff and students to provide enhanced care to patients transitioning from the hospital back home are now being studied to better measure their effectiveness at preventing hospital readmissions.
For the past two years, health care professionals at ETSU Family Physicians of Kingsport have been providing an interprofessional transitions of care (IPTC) clinic for their patients who frequently are hospitalized due to some kind of chronic condition.
“We know that transitions of care – hospital to home, home to hospital, hospital to rehabilitation, skilled nursing facility to home – are places in the continuum of care that provide a significant opportunity for error, confusion and frustration for many patients,” said Dr. McKenzie Calhoun, a member of the IPTC team and an assistant professor in the Bill Gatton College of Pharmacy at ETSU. “There are often times when medication changes, new physicians have to be seen, and possibly changes occur in the ability of a person to take care of himself or herself. It’s also a time when a lot of money is spent by the patient, insurance or health care system.”
Some of that money, Calhoun said, may be being spent unnecessarily.
“For a while now, hospital readmissions have been an area of focus for health systems to try to reduce,” she said. “We’re looking at a shift so that the primary care physician and team are also focused on that.
“We aim to prove that coming to an outpatient IPTC clinic soon after discharge can improve outcomes and decrease overall costs and health care utilization.”
Prior to being discharged from the hospital, a patient receives an appointment date and time for their IPTC clinic visit.
“We aim to get every single patient in within seven days of discharge,” Calhoun said. “Within two days of getting home from the hospital, our social worker on the IPTC team calls and checks on the patient and reminds them of the appointment.”
On the day before the weekly IPTC clinic, pharmacy students work up the files of those patients who will be seen the next day, assessing their most recent medication changes and other health details from their hospital stays. Then, on the morning of the clinic, the health care team, which includes a pharmacist, one to two physician residents, a social worker and both pharmacy and medical students, meets to discuss each patient coming in that day.
“That is our time as a team to get on the same page,” Calhoun said. “We identify our own little to-do lists.”
During the IPTC clinic, patients are seen in roughly 30-minute blocks, much longer than an average primary care visit. During that time, they see all members of the health care team.
By the time the visit is complete, the team has gone over medications, done a physical assessment of the patient, offered community resources, coordinated any other follow-up appointments with primary care physicians and answered patient questions.
“Our patients love it,” Calhoun said. “Now we want to prove that we are meeting our goals of preventing readmits as well as preventing errors that can happen during transitions of care.”
Through a $10,000 Research Development Grant from ETSU, Calhoun is using data collected over the past two years to determine just how well the IPTC is working.
“I really feel strongly that what we are doing is valuable,” she said. “And if it proves to be the case, we have an obligation to share our best practices with others all over the country.”