Transitional Primary Care Clinic - Care Coordination across the Continuum

Access to primary care services is a central component to a patient’s successful transition after a hospitalization or an emergency department (ED) visit. For a variety of factors, not all patients have equitable access to primary care, which can lead to more frequent hospital readmissions and unnecessary ED visits. Our transitional primary care clinic serves to address the needs of our discharging and ED follow-up patients who are unaffiliated with a PCP. This directly addresses two less tangible goals: reduce avoidable hospital recidivism and minimize the use of emergency services for clinic-level care.

Our clinic is part of a large county hospital that is our area’s safety net facility as well as the only level I trauma center in our state. Our primary mission is to provide healthcare for the most vulnerable residents of our county, teach exemplary patient care, and provide care for a broad spectrum of patients from throughout the region.

Population: We see vulnerable patients including homeless, non-English speaking, and immigrants new to the medical system. Additionally, we see a high number of patients with substance use disorders or behavioral health diagnoses. More than 44% of our patients are uninsured at the time of their visit.

Criteria for care: Patients are referred from our ED or by inpatient providers at the time of hospital discharge. Patient must have acute medical needs that require follow-up and be medically unaffiliated in order to be seen in our clinic.

Inpatient discharges: We complete a warm handoff from the discharging team to the clinic staff. Our clinic staff completes care coordination that helps address patient’s barriers to accessing care, which could include funding status, transportation issues, housing, immigration status, complex medical comorbidities, and behavior health and opioid use disorder diagnoses.

Partnerships: We have developed partnerships with various programs in order to coordinate complex aspects of care. These include King County Jail, office-based opioid treatment program (OBOT), ED high-utilizer case management, and both internal and external primary care provider (PCP) offices. We provide a medical bridge for recently released inmates to ensure transitions of care from jail to their PCP. The OBOT program utilizes our facility and staff with weekly visits. We also partner with our ED high-utilization social workers to provide immediate medical care for patients who are challenging to engage.

Research: A retrospective study was completed from 2013-2014 that looked at a random sample of 660 patients that were scheduled in our clinic post-ED discharge. The research showed patients who completed an appointment in our clinic had fewer total ED visits in the year following, with an average of one less ED visit per patient after adjusting for demographic and clinical characteristics. We are currently gathering outcomes data related to our inpatient discharge patients. We hope to have more definitive data in early 2019.

With ever-increasing value placed upon transitions of care, we have shown that our clinic model can positively impact our patient outcomes and our institution’s financial bottom line.