2015 APHA Annual Meeting & Expo

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Recorded Annual Meeting Presentations (RAMP) are now available for purchase.
Only $90 for presenters, $140 for registered attendees and $200 for non-attendees.

Online Program

333348
A Primary Care Physician-Staffed Transition Clinic and Hospital Readmissions


Tuesday, November 3, 2015 : 5:10 p.m. - 5:30 p.m.

Vidya Chakravarthy, Department of Health Systems Management, Rush University Medical Center, Chicago, IL
Tricia Johnson, PhD, Rush University, Department of Health Systems Management, Chicago, IL
Amir Jaffer, MD, MBA, Rush University Medical Center, Chicago, IL
Mary Ryan, RN, MHPE, Rush University Medical Center, Chicago, IL
Regina McClenton, RN, Rush University Medical Center, Chicago, IL
Robyn Golden, AM, LCSW, Department of Health and Aging, Rush University Medical Center, Chicago, IL
Jisu Kim, MD, FHM, Rush University Medical Center, Chicago, IL
Irwin Press, PhD, Rush University Medical Center, Chicago, IL
Audio (mp3) recording Recorded Presentation (mp4)
Background:A primary care-staffed transition clinic (TC) is one potential strategy for reducing 30-day readmissions for patients without an established primary care physician (PCP), but the effectiveness has not yet been studied. The objective was to test whether patients who complete a post-discharge TC appointment are less likely to be readmitted within 30 days.

MethodsThe sample included adults with Medicare and Medicaid coverage discharged from general medicine units at Rush University Medical Center between October 2013 and October 2014 with a post-discharge appointment scheduled within 30 days of discharge in either the TC or with their PCP. A binary logistic regression model was used to test the relationship between 30-day readmission and follow-up appointment status, controlling for patient factors.

Results: This sample included 1,162 patients (24% in the TC and 76% with their PCP). After controlling for patient demographic characteristics and clinical factors, patients who did not complete a scheduled TC appointment were 3 times more likely to be readmitted than patients who completed a TC appointment (20.3% vs. 8.7%; p = 0.004). There was no significant difference in 30-day readmissions between patients completing a TC appointment and those who were scheduled with their PCP.

Conclusion: A primary care-staffed TC is a promising strategy for providing access and effectively managing the initial post-hospital discharge needs of vulnerable populations.

Learning Areas:

Administer health education strategies, interventions and programs
Administration, management, leadership
Implementation of health education strategies, interventions and programs

Learning Objectives:
Assess the effect of a PCP-run post-discharge clinic on hospital readmissions.

Keyword(s): Vulnerable Populations, Accessibility

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am completing my master’s degree in Health Systems Management and have spent the past two years researching and operationalizing care coordination models for post-discharge care.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 4439.0: Primary Care Services Utilization and Hospital Readmissions by Underserved Populations