Evaluating the effectiveness of an interdisciplinary clinic: a one-stop shop for high-risk Medicare patients

Interprofessional collaboration is a critical component of high-quality, patient-centered care, particularly for high-risk Medicare patients. In response to the growing need for coordinated care, an interdisciplinary clinic was launched at Baylor Scott & White Health to provide integrated medical and social services.

A retrospective pre-post study design was used to evaluate outcomes in the pilot program. Eligible participants were referred to the interdisciplinary clinic based on the complexity of their needs and had completed at least one comprehensive clinic visit during the index period.

A total of 586 patients were eligible. The mean change from baseline to follow-up in number of emergency department visits per patient decreased from 0.09 ± 0.41 to 0.08 ± 0.31 (P = 0.75), the number of hospitalizations per patient decreased from 0.17 ± 0.46 to 0.15 ± 0.49 (P = 0.38), and the 30-day readmission rate increased from 1.00% to 1.87% (P = 0.33). Secondary outcomes assessing blood pressure, lipids, and hemoglobin A1c levels demonstrated improvements.

While not statistically significant, the results of this study suggest that the interdisciplinary clinic demonstrates promise in closing healthcare gaps and improving outcomes for high-risk patients through interprofessional collaboration.