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Transitional Care Clinics to Reduce Readmissions

The Problem:
Ineffective care transitions processes lead to an increase in adverse events for patients, more frequent readmissions and higher healthcare costs. One recent study suggests that 4 out of 5 serious medical errors involve miscommunication during a patient’s transition between different medical providers.

The Goal:
In an effort to reduce readmissions, Self Regional Healthcare established a Transitional Care Clinic, a short-term medical home for high-risk patients who need careful assistance in managing their care due to the complexity of their health status and degree of healthcare literacy. The goal of the clinic is to provide a bridge between hospital and primary care for patients who need additional support in managing their own care.

Method & Implementation:
Self Regional Healthcare began their short-term Transitional Care Clinic in Clinica Gratis, one of the free clinics in Greenwood, SC, with grant money to pay a minuscule staff. Doctors who work for the clinic are freed from standard productivity requirements with the recognition that these patients need more time and troubleshooting than traditional primary care is equipped to provide, whether that means something small like additional education or as complicated as financing or transportation support.

The clinic uses a holistic approach to care, allowing all members of the team to perform at the top of their license. This allows the clinic to identify barriers so the nurses, social workers and community health workers can help complex patients.

After these more involved visits to the transitional care clinic, the handoff to the medical home is easier, allowing patients to get into a truly permanent medical home.

Challenges & Barriers:
Funding and sustainability
Coordinating with community partners
Changing from an RVU-based culture to a transitional care culture

Reduction of low acute, non-emergent ER visits
Reduction of all-payer readmission rate from 13.96% in 2015 to 10.59% in 2016

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