Bridging the Gap Between Inpatient and Outpatient Care.

Area of Science:

• Internal Medicine
• Healthcare Management
• Patient Care

Background:

• Olin E. Teague Veterans' Center (OETVC) is a 189-bed teaching hospital.
• Complex hospitalizations raise concerns about post-discharge patient follow-up and medication adherence.

Purpose of the Study:

• To implement a program bridging inpatient and outpatient care.
• To improve patient outcomes and reduce hospital readmissions.

Main Methods:

• Internal medicine residents conduct post-discharge follow-up calls to teaching team patients.
• Calls include medication review, symptom assessment, and addressing patient questions.
• Residents assist with missed orders and treatment adjustments.

Main Results:

• Reduced 30-day readmission rate from 10% to 6% in the transition of care group.
• Residents improved understanding of illness scripts and communication skills.
• Patients gained physician access for post-discharge concerns.

Conclusions:

• The transition of care program is beneficial for patient outcomes.
• The program enhances resident training in communication and clinical reasoning.
• Continued adaptation of the program aims to further improve care transitions.