Transitional care clinics: An innovative approach to reducing readmissions, optimizing outcomes and improving the patient’s experience of discharge care-conducting a feasibility study

Abstract

Rehospitalization, which is defined as a return to the hospital for the same or related care within 30 days, is often avoidable and adds significant costs to health care spending. A growing body of evidence indicates that when patients move from one health care setting to another, a period known as the care transition, timely access to follow–up care is one of the keys to avoiding unplanned readmissions. Of late, transitional care clinics (TCCs), sometimes referred to as post-discharge clinics, have emerged as an innovative approach to readmission reduction. TCCs bridge the care gap between hospital discharge and post-acute care follow-up by providing access to care for patients with fragmented care or at high risk for readmission. These clinics are typically hospital-based and nurse practitioner-led which makes sense in terms of both cost-containment and quality of care. They provide an alternative to the use of emergency services, improve workflow for referring physicians, and support care navigation back to community providers. TCCs support the discharge plan of care and long-term outcomes by providing an intense focus on patient education, disease and medication self-management, and coordination of care. By providing access to care and improving communication across the continuum of care, TCCs can improve the quality of the care transition and reduce avoidable readmissions. A feasibility analysis can help to provide answers and guide project planning. This article describes how to conduct such a feasibility analysis of establishing a TCC as well as the organizational, financial and market factors impacting the feasibility of establishing such a clinic.