Post-discharge Appointments Research Articles

Importance of GP contact on readmission rate following psychiatric acute care: A Danish Nationwide study

Insufficient acute psychiatric care substantially impacts patient well-being and healthcare quality. Early readmissions after discharge from psychiatric care are common, and preventing these is important for the patients as well as appropriate resource allocation. The relationship between post-discharge general practitioner (GP) contact and readmission rates remains to be explored, as does the association between pre-hospital GP contact and post-discharge engagement. AimThis study examines post-discharge GP contact and its association with outpatient revisits and inpatient readmissions among unplanned psychiatric hospital contacts, including the impact of pre-visit GP contact on post-discharge care within 14 days. MethodsUtilizing data from the Danish healthcare system (2019–2023), unplanned psychiatric hospital contacts and subsequent 14-day GP encounters were analyzed. ResultsOf 298,085 unplanned psychiatric hospital contacts, 12.6% had a 14-day revisit as an outpatient and 13.6% had a 14-day readmission as an inpatient. During regular business hours, GP contact was associated with a decreased risk of unplanned outpatient revisits (HR 0.45, 95% CI 0.44–0.47) and inpatient readmissions (HR 0.43, 95% CI 0.41–0.44). Similarly, utilizing GP on-call services was linked to a reduced risk of unplanned revisits (HR 0.87, 95% CI 0.81–0.94) and readmissions (HR 0.81, 95% CI 0.76–0.87). Having a GP contact within two days before an unplanned psychiatric hospital contact increased the likelihood of having a GP contact within 14 days post-discharge. ConclusionPost-discharge GP encounters were associated with lower rates of 14-day outpatient revisits and inpatient readmissions following unplanned psychiatric hospital contacts. GP contact before psychiatric hospital contact enhances attendance at post-discharge appointments, suggesting a potential efficacy of promoting GP appointments for mental health care.

Heart failure early post-discharge appointment: a 1.5-year single-centre experience

Abstract Background According to Heart Failure (HF) guidelines, a follow-up visit should be conducted within 1 to 2 weeks after hospital discharge to monitor signs and symptoms of HF, optimize therapy, and evaluate treatment side effects. Retrospective studies have shown that this approach is associated with lower 30-day readmission rates. Purpose Our aim is to describe the role of early post-discharge appointment in the management of HF patients and to evaluate prognostic factors after HF hospitalization. Methods We conducted a single-centre prospective registry of consecutive patients evaluated in the early post-discharge appointment at our centre, from March 2021 to September 2022. HF symptoms, vital signs, blood test results, treatment decision, and 90-day HF events were recorded. Results Overall, 153 patients were included (mean age 65.7 ± 13.0 years, 63.4% male). The mean time from hospital discharge to post-discharge appointment was 13.4 ± 5.7 days. Left ventricle ejection fraction was reduced in 83.6% (n = 127) of patients. Guideline-directed medical treatment prescribed at discharge, as well as up-titration and withdrawal patterns at the post-discharge appointment, are presented in Table 1. At the post-discharge appointment, 34.3% of patients (n = 35) presented with drug adverse effects, most often including hyperkalemia (17.5%, n = 22), acute kidney injury (9.9%, n = 12), and hypotension (3.9%, n = 6). Of those evaluated at the post-discharge appointment, 11.2% (n = 17) were scheduled to another appointment one week later, for early re-evaluation, 90.1% (n = 137) were followed-up in the standard HF ambulatory program, and 2.6% (n = 4) were hospitalized. The serum creatinine (1.10 [0.87 – 1.36] mg/dL vs 1.40 [1.09 – 1.95] mg/dL, p<0.001), the serum C cystatin (1.50 [1.25 – 1.98] mg/dL vs 1.97 [1.54 – 2.46] mg/dL, p = 0.007) and the NT-proBNP levels (1859 [977 – 4877] mg/dL vs 5928 [2817 – 11957] mg/dL, p = 0.013), measured at the time of the post-discharge appointment, were found to be associated with HF events within 90 days (urgent HF visit or HF hospitalization). An NT-proBNP level above 2400 pg/mL adjusted to C cystatin was found to be a strong predictor of 90-day HF events (OR 9.855, 95% CI 2.657 – 36.550, p = 0.001). This model yielded a good prognostic performance (AUC 0.790, CI 95% 0.689-0.890, p<0.001). Conclusions Early evaluation of HF patients after hospital discharge allows for guideline-directed medical therapy up-titration and early detection of drug adverse effects. The NTproBNP level and kidney function, assessed early after discharge, have been found to be strong predictors of 90-day HF events, indicating which patients would benefit most from a stricter follow-up program. Table 1 – Guideline-directed medical therapy patterns of prescription both at hospital discharge and during the early post-discharge appointment. ACE, angiotensin converting enzyme; ARA, aldosterone receptor antagonist, MRA, mineralocorticoid receptor antagonist.

Abstract 17028: Characteristics and Short-Term Outcome of Patients in the Program “Get With the Guidelines” - One Vietnamese Center Registry

Background: “Get with the guidelines HF” is a program with the aim of properly applying heart failure treatment recommendations into clinical practice and improving the outcome of patients. This study evaluated the initial result of the implementation of the program in one Vietnamese center. Method: This is a prospective, one-center, observational registry in Hanoi Heart Hospital, Vietnam. Hospitalized heart failure patients over 18 years old with reduced and mild reduced left ventricular ejection fraction (LVEF) were enrolled. Data included demographic characteristics, comorbidities, discharge medications, and post-discharge appointment plans. Results: From September 2021 to December 2022, 749 patients were included in the study with a mean age of 65. The male and female ratio was 56.1% and 43.9% respectively. 65.3% of the patients had reduced LVEF and 34.7% had mild reduced LVEF. Coronary heart disease was the most popular comorbidity and was diagnosed in 44.6% of patients. At discharge, after excluding drug contraindications, the rate of prescribing of RASi drugs (ACEi, ARB or ARNI), beta-blocker, mineralocorticoid receptor antagonists (MRA), SGLT2i were 97.56%, 92.86%, 96.15%, 57.14%, respectively in Q4.2021. At discharge, the rate of using these 4 drugs in Q4.2022 was 99.15%, 100%, 100%, and 85.19%, respectively. The rate of patients receiving all 4 GDMT drugs according to ACC/AHA guidelines in Q4.2021 and Q4 2022 was 28.8% và 41.4%. The percentage of patients using 3 and 2 GDMT drugs in the times mentioned above was 33.3% and 35.4% and 24.2% and 14.8%, respectively. Short-term follow-up showed that 30-day re-admission was 2.94% and the 30-day mortality after discharge was 0%. Conclusion: “Get with the guidelines” helps to implement guidelines to daily practice, especially the use of GDMT drugs, and gives promising results to improve the outcome for patients with heart failure. Keywords: heart failure, GDMT, Get with the guideline

The transition tightrope: Optimizing post-discharge care for acute leukemia patients.

323 Background: Patients with acute leukemia who are discharged after a hospitalization are at high risk of complications and increased risk of readmissions. We reviewed discharge plans at an academic cancer center and found a gap of inconsistently scheduled follow-up appointments after discharge, and we sought to improve the transition of care for this population. Methods: Utilizing A3 methodology, we focused on ensuring acute leukemia patients had a follow-up visit in the clinic or infusion treatment area within 5 days of discharge, which was the timeline supported by literature review. Our improvement team performed a Gemba walk in November 2021 to observe discharge planning and outpatient follow-up appointment scheduling processes, and we mapped root causes of poor care transitions on a fishbone diagram. Many of the coordinated steps required for a seamless discharge and acceptance into outpatient care were not consistently performed. We utilized a pareto chart to stratify root causes and narrowed in on 3 key drivers: 1) standard process for discharge communication between in- & out-patient teams; 2) access to schedulers to secure appointments; and 3) escalation pathways when no appointment slots were available. We introduced 3 interventions: a direct phone line for the inpatient team to contact the infusion area schedulers for post-discharge appointments, an escalation pathway when schedules appeared fully booked, and a discharge navigator flowsheet in our electronic medical record (EMR) to anticipate discharge needs and facilitate standardized, efficient communication. Results: As a result of our interventions, the percentage of patients with an outpatient follow-up visit within 5 days increased from 61% to 94% between January and May 2022. Streamlining communication pathways (e.g., an automated EMR message to schedulers and a direct phone line for urgent escalation) led to initial improvements in timely follow-up visits. The EMR discharge navigator facilitated upstream identification of post-discharge needs and directed communication to the appropriate infusion area and clinic pools to schedule appointments. The discharge navigator continues to be used in the hematology service; one year after its launch, the EMR tool is utilized in 38% of all hematology discharges. Conclusions: Timely outpatient follow-up to address acute symptoms is a key method to decrease readmission risk, but inconsistent scheduling practices presented barriers at our cancer center. Instituting standardized scheduling protocols in the EMR and escalation pathways enabled nearly all our patients with acute leukemia to secure outpatient visits within 5 days of discharge. We are building on these initial efforts to disseminate and sustain utilization of the tool for all hematology and oncology patients in our center.

Novel Discharge Center for Transition of Care in Vulnerable Emergency Department Treat and Release Patients.

Introduction The majority of emergency department (ED) patients are discharged following evaluation and treatment. Most patients are recommended to follow up with a primary care provider (PCP) or specialist. However, there is considerable variation between providers and EDs in discharge process practices that might facilitate such follow-up (e.g., simply discharging patients with follow-up physician names/contact information vs. making appointments for patients). Patients who do not follow up with their PCPs or specialists are more likely to be readmitted within 30 days than those who do. Furthermore, vulnerable patients have difficulty arranging transitional care appointments due to poor health literacy, inadequate insurance, appointment availability, and self-efficacy. Our innovative ED discharge process utilizes an Emergency Department Discharge Center (EDDC) staffed by ED Care Coordinators and assists patients with scheduling post-discharge appointments to improve rates of follow-up with outpatient providers. This study describes the structure and activities of the EDDC, characterizes the EDDC patient population, and demonstrates the volume and specialties of appointments scheduled by EDDC Care Coordinators. The impact of the EDDC on operational metrics (72-hour returns, 30-day admissions, and length-of-stay [LOS]) and the impact of the EDDC on patient satisfaction are evaluated. Methods The Long Island Jewish Medical Center (LIJMC) EDDCis an intervention developed in July 2020 within a 583-bed urban hospital serving a racially, ethnically, and socio-economically diverse population, with many patients having limited access to healthcare. Data from the Emergency Medicine Service Line (EMSL), an ED Care Coordinator database, and manual chart review were collected from July 2020 to July 2021 to examine the impact of the EDDC on 72-hour returns, 30-day admissions, and Press Ganey's® "likelihood to recommend ED" score (a widely used patient satisfaction survey question). The EDDC pilot cohort was compared to non-EDDC discharged patients during the same period. Results In unadjusted analysis, EDDC patients were moderately less likely to return to the ED within 72 hours (5.3% vs. 6.5%; p = 0.0044) or be admitted within 30 days (3.4% vs. 4.2%). The program was particularly beneficial for uninsured and elderly patients. For both EDDC and non-EDDC patients, most revisits and 30-day admissions were for the same chief complaint as the index visit. The length-of-stay increased by ~10 minutes with no impact on satisfaction with ED visits. Musculoskeletal conditions (~20%) and specialties (~15%) were the most commonly represented. Approximately 10% of referrals were to obtain a PCP. Nearly 90% were to new providers or specialties. Most scheduled appointments occurred within a week. Conclusion This novel EDDC program, developed to facilitate outpatient follow-up for discharged ED patients, produced a modest but statistically significant difference in 72-hour returns and 30-day admissions for patients with EDDC-scheduled appointments vs. those referred to outpatient providers using the standard discharge process. ED LOS increased by ~10 minutes for EDDC vs. non-EDDC patients, with no difference in satisfaction. Future analyses will investigate impacts on 72-hour returns, 30-day admissions, LOS, and satisfaction after adjusting for characteristics such as age, insurance, having a PCP, and whether the scheduled appointment was attended.

Abstract 56: Predictors Of Post Stroke Discharge Follows-ups In The Stroke Clinic And Role Of A Stroke Navigator To Improve Follow-ups

Objective: We aimed to evaluate which factors contributed to acute ischemic stroke (AIS) following up in stroke clinic post hospitalization. Methods: Single center retrospective analysis of AIS patients from January 2016 to April 2021. Patients were excluded if: died during index hospitalization, discharged to hospice or had incomplete data. We evaluated our primary outcome: factors contributing to patients attending post-discharge appointments and secondary outcome: factors contributing to patients scheduling post-discharge appointments utilizing binomial stepwise logistic regression models. Subgroup analysis compared latency to be seen in follow-up clinic between patients who had an appointment scheduled at discharge compared to those who did not using a Mann-Whitney test. Results: Out of 7960 AIS patients, 2734 were included in this study, 2130 (77.9%) of those patients scheduled an appointment post-discharge, whereas 1649 (60.3%) attended an appointment post-discharge. Patients were more likely to attend a follow-up appointment if scheduled while hospitalized, OR=3.48 [95%CI, 2.94-4.14], p<0.001 and less likely if: older OR=0.98 [95%CI 0.97-0.98], p<0.001; admitted for a longer duration, OR=0.98 [95%CI, 0.96-1.00], p=0.05; lived farther away OR=0.99 [95%CI, 0.96-0.99], p<0.001 or had higher modified Rankin Scale (mRS) at discharge OR=0.73 [95%CI, 0.69-0.79], p<0.001. Patients were more likely to schedule a follow-up appointment after initiation of the AIS navigator program, OR=8.52 [95%CI, 6.59-10.57], p<0.001.Patients with follow-up appointments scheduled during their initial hospitalization were seen in clinic sooner; 27 days (IQR 19-36) versus 37 days (IQR 22-61), p<0.001. Conclusion: Patients with AIS were more likely to schedule an appointment after initiation of a nurse navigator program. Patients were also more likely to attend post-discharge stroke clinics if their appointments were scheduled during index hospitalization.

Substance Use/Dependence in Psychiatric Emergency Setting Leading to Hospitalization: Predictors of Continuity of Care.

Background: Poor adherence to treatment is a common clinical problem in individuals affected by mental illness and substance use/dependence. In Italy, mental care is organized in a psychiatric service and addiction unit (SERD), characterized by dual independent assets of treatment. This difference, in the Emergency Room setting, leads to a risk of discontinuity of treatment in case of hospitalization. In this study we clinically characterized individuals who decided to attend hospital post-discharge appointments at SERD, in accordance with medical advice. Methods: This is a retrospective study, based on two years of discharged records of patients entering “Versilia Hospital” (Viareggio, Italy) emergency room, with urinalyses testing positive for substance use, and hospitalization after psychiatric consultation. The sample was divided according to the presence or absence of SERD consultation after discharge. Results: In the 2-year period of the present study, 1005 individuals were hospitalized. Considering the inclusion criterion of the study, the sample consisted of 264 individuals. Of these, 128 patients attended post-discharge appointments at SERD showing urinalyses positive to cocaine, opiates, and poly use; they were more frequently diagnosed as personality disorder and less frequently as bipolar disorder. The prediction was higher for patients that had already been treated at SERD, for patients who received SERD consultation during hospitalization, and for patients with positive urinalyses to cocaine and opiates at treatment entry. Conversely, patients who did not attend SERD consultation after discharge were affected by bipolar disorders. Limitations: Small sample size. Demographical data are limited to gender and age due to paucity of data in hospital information systems. SERD is located far from the hospital and is open only on weekdays; thus, it cannot ensure a consultation with all inpatients. Conclusions: Mental illness diagnosis, the set of substance use positivity at hospitalization, and having received SERD consultation during hospitalization appeared to have a critical role in promoting continuity of care. Moreover, to reduce the gap between the need and the provision of the treatment, a more effective personalized individual program of care should be implemented.

EP.WE.727Upper GI Surgery Clinic Referrals; Can We Improve the Patient Experience?

Abstract Aim To review the new referrals to the Upper GI surgery clinic for appropriateness, investigations requested, and waiting times and to identify potential pathways to reduce waiting times and improve the patient experience. Method Patients who attended the UGI clinic over 2 months period were identified. Data were collected from GP referrals and Electronic Patient Records. Follow up, post-discharge appointments, and Did Not Attends were excluded. Data collected included time from referral to first clinic, symptoms, investigations requested, suitability for a pathway, and appropriateness of referral. A first clinic outcome was concluded from reading the GP referral, there were 5 outcomes to choose from; direct to another specialty, discharge back to GP, clinic, surgery, pre-investigate and clinic. Results 147 referrals were analysed. The average waiting time from referral to the first clinic was 51 days (range 7-119 days). 73% of the referrals were GP referrals and 27% from other specialties. The most common referral was for gallstones and the most common 2 outcomes were Pre-investigate and surgery. Conclusion Most of the investigations and outcomes suggested from the project were the same as those from clinic letters. The following pathways can be developed to cut waiting times and costs for the trust:

499 Upper GI Surgical Clinic Referrals, Can We Improve Patient Experience?

IntroductionWith increasing pressure on NHS to deal with long waiting lists, solutions to reduce waiting times are imperative. In the era of the COVID-19 pandemic, we need to reshape the way we look into Outpatient clinic appointments.AimTo review all clinic referrals to UGI surgical clinic and highlight any potential pathways that can improve waiting times and patient experience.MethodPatients referred to UGI clinic over 2 months were collected from Iclip, EPR and EDM. Post-discharge appointments and DNA’s were excluded. Data collected included time from referral to clinic, type of referral, symptoms, investigations, potential pathway, first clinic outcome, and appropriateness of referral.ResultsTotal of 147 referrals analyzed. Time from referral to clinic appointment is 51 days. GP referrals represented 73% while the rest from consultant colleagues. The most common symptoms were biliary colic and GORD. OGD and PH manometry were the most common investigations requested. The most common first outcome was pre investigate and clinic follow up. Two potential pathways identified are Biliary colic and GORD pathway. 90% of referrals were appropriate.ConclusionsBiliary colic pathway and GORD pathway are 2 potential pathways that can cut off waiting times for clinic appointments and improve patient experience in outpatient clinics.

Examination of Post-discharge Follow-up Appointment Status and 30-Day Readmission.

Post-hospital discharge follow-up appointments are intended to evaluate patients' recovery following a hospitalization, but it is unclear how appointment statuses are associated with readmissions. To examine the association between post-discharge ambulatory follow-up status, (1) having a scheduled appointment and (2) arriving to said appointment, and 30-day readmission. A retrospective cohort study of patients hospitalized at 12 hospitals in an Integrated Delivery Network and their ambulatory appointments in that same network. We included 50,772 patients who had an ambulatory appointment within 18 months of an inpatient admission in 2018. Primary outcome was readmission within 30 days post-discharge. There were 32,108 (63.2%) patients with scheduled follow-up appointments and 18,664 (36.8%) patients with no follow-up; 28,313 (88.2%) patients arrived, 3149 (9.8%) missed, and 646 (2.0%) were readmitted prior to their scheduled appointments. Overall 30-day readmission rate was 7.3%; 6.0% [5.75-6.31] for those who arrived, 8.8% [8.44-9.25] for those without follow-up, and 10.3% [9.28-11.40] for those who missed a scheduled appointment (p < 0.001). After adjusting for covariates, patients who arrived at their appointment in the first week following discharge were significantly less likely to be readmitted than those not having any follow-up scheduled (medical adjusted hazard ratio (aHR)0.57 [0.47-0.69], p < 0.001; surgical aHR 0.58 [0.44-0.75], p < 0.001) There was an increased risk at weeks 3 and 4 for medical patients who arrived at a follow-up compared to those with no follow-up scheduled (week 3 aHR 1.29 [1.10-1.51], p = 0.001; week 4 aHR 1.46 [1.26-1.70], p < 0.001). The benefit of patients arriving to their post-discharge appointments compared with patients who missed their follow-up visits or had no follow-up scheduled, is only significant during first week post-discharge, suggesting that coordination within 1 week of discharge is critical in reducing 30-day readmissions.

2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure

2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure

Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure

Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care. To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare. Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry. Medicare Advantage enrollment. In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures. Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42). Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.

Improvement in Outpatient Follow-up With a Postdischarge Phone Call Intervention

Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit. This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit. Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001). Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.

Palliative care referral patterns of adolescent and young adult patients at a comprehensive cancer center.

63 Background: Adolescent and young adults (AYA) diagnosed with cancer have distinct physical, developmental and psychosocial needs that are often unmet during oncology treatment. Such needs are further intensified for AYA patients with an advanced cancer diagnosis. Palliative Care (PC), specialized care for patients and families with serious illness, can address these needs throughout the disease trajectory including symptom management, supportive communication, and advance care planning. The incorporation of PC remains suboptimal despite evidence that palliative services can improve quality of life. In an effort to identify strategies to advance access to PC for the AYA population at our institution, the referral pattern to PC was studied. Methods: A retrospective chart review was performed to identify referral patterns to PC in the AYA population (ages 18-39) from July 2017 through June 2019 at a National Cancer Institute designated comprehensive cancer center. Descriptive statistics were utilized to summarize referral patterns and trends. Results: In the past 2 years, 1,894 AYA patients established oncology care at our institution. The most common AYA cancer diagnoses included hematologic 20.8% (n=944), thyroid 10.8% (n=490), brain 9.9% (n=451) and breast 9.1% (n=414). There were 311 (16%) referrals placed to PC, mostly in the inpatient setting (81.4%). Less than half (43%) of the inpatient referrals had a post-discharge follow-up appointment in the PC clinic. Multiple disease-specific service lines were represented including leukemia (40%), colorectal (14.5%), sarcoma (9%) and breast (9%). Quarterly volumetric trends remained static over the 2 years (average number of referrals: 54/quarter). The average age at cancer diagnosis in the AYA population was 30 years and 32.7 years (range 19-39) at time of PC referral. This was consistent with the average length of time from initial diagnosis to PC referral of 2.8 years. Conclusions: Comprehensive oncology care in the AYA population should include PC. Yet, involvement of PC in the AYA population during oncologic treatment was limited. Future research will investigate optimal models of integrative PC to address the unique needs of AYA cancer.

Does Scheduling a Postdischarge Visit with a Primary Care Physician Increase Rates of Follow-up and Decrease Readmissions?

Driven in part by Medicare's Hospital Readmissions Reduction Program, hospitals are focusing on improving the transition from inpatient to outpatient care with particular emphasis on early follow-up with a primary care physician (PCP). To assess whether the implementation of a scheduling assistance program changes rates of PCP follow-up or readmissions. Retrospective cohort study. An urban tertiary care center PATIENTS: A total of 20,918 adult patients hospitalized and discharged home between September 2008 and October 2015. A postdischarge appointment service to facilitate early PCP follow-up. Primary outcomes were rates of follow-up visits with a PCP within seven days of discharge and hospital readmission within 30 days of discharge. Our first analysis assessed differences in outcomes among patients with and without the use of the service. In a second analysis, we exploited the fact that the service was not available on weekends and conducted an instrumental variable analysis that used the interaction between the intervention and day of the week of admission. In our multivariable analysis, use of the appointment service was associated with much higher rates of PCP follow-up (+31.9 percentage points, 95% CI: 30.2, 33.6; P < .01) and a decrease in readmission (-3.8 percentage points, 95% CI: -5.2, -2.4; P < .01). In the instrumental variable analysis, use of the service also increased the likelihood of a PCP follow-up visit (33.4 percentage points, 95% CI: 7.9, 58.9; P = .01) but had no significant impact on readmissions (-2.5 percentage points, 95% CI: -22.0, 17.0; P = .80). The postdischarge appointment service resulted in a substantial increase in timely PCP followup, but its impact on the readmission rate was less clear.

423 Identifying Burn Patient Challenges with Implementation of Follow-Up Phone calls

After hospitalization, some burn patients find the transition to the outpatient setting to be challenging. Patients are sometimes overwhelmed by discharge instructions and can miss many important details. As a result, some patients have experienced graft failure or infection due to poor wound care, ineffective pain control, or inadequate out-patient services. We have implemented follow-up phone calls to all discharged patients to attempt to improve patient outcomes. The pilot study of follow-up phone calls ran for four months. During this time, every patient seen or discharged from the Burn Center received a phone call from the assistant nurse manager within a week of discharge. Topics for the phone call included: general well-being, dressing changes, understanding of discharge instructions, medication, ancillary services including skilled nursing and occupational and physical therapy, and assistance with follow-up appointments. The need for and type of intervention subsequently undertaken was recorded. Fifty-two patients were included in this study, 21 (40%) of whom required intervention. Six (11.5%) had VNA that did not arrive or VNA nurses who were uncomfortable caring for the patient’s wounds. Nine (17.3%) needed interventions with either dressings or prescribed medications. Ten (19.2%) had either expedited wound center visits or new appointments made due to pain or infection risk. Despite detailed written discharge instructions and verbal review of those instructions prior to discharge, patients often require further assistance to obtain optimal care when they leave the hospital. By implementing routine follow-up telephone calls with discharged patients, we were able to identify patients requiring assistance. These included issues such as making post-discharge appointments, arrangements for services (skilled nursing visits; occupational and physical therapy), and the need for medication adjustment. This intervention also assisted with early detection of patients who had difficulty with dressing changes and showed signs of infection or graft failure, and expedited follow-up care in the outpatient setting. We conclude that the follow-up phone calls helped to identify and address challenges that arise for a significant number (40%) of patients and families when being discharged to home. Continuing research will determine if follow-up phone calls help prevent readmission rate and infection rates post-burn. Early identification of potential issues that may complicate the patient’s both short and long term outcome. Evaluating the relevance of patient challenges will improve patient outcomes.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

Transitions in Care From Acute Care Telemetry Unit to Home: An Evidence-Based Quality Improvement Project.

303 Early Identification and Intervention in Patients With Atrial Fibrillation in the Emergency Department Can Significantly Improve Guideline-Based Anticoagulation and Reduce the Risk of Stroke

Although nonvalvular atrial fibrillation (NVAF) patients are at a 4 to 5-fold increased risk of stroke, high-risk patients are undertreated. The PINNACLE Registry reported that 40.2% of patients with a CHA2DS2-VASc score greater or equal to 2 are treated with aspirin only, despite American College of Cardiology and American Heart Association Guideline recommendations for anticoagulation. Sharp Chula Vista Medical Center piloted a study in the emergency department (ED) involving a multidisciplinary team approach to manage the treatment gap in this population. The team consists of emergency physicians, electrophysiologists (EP) and the ED pharmacist, all collaborating in a shared decisionmaking model to identify, assess, and initiate guideline-based oral anticoagulation (OAC) in high-risk NVAF patients. We aim to decrease the treatment gap by utilizing a multidisciplinary approach to increase the percentage of properly anticoagulated high-risk patients at discharge. The study will compare the percentage of patients on OAC at admission and discharge for the baseline group vs intervention group (multidisciplinary team) to observe if our method will significantly impact the treatment gap. All NVAF patients were identified by EKG or device interrogation by the emergency physician upon arrival. A standardized risk-scoring process and referral to the EP Panel for consult was established to evaluate all patients presenting to the ED with a diagnosis of NVAF. The ED pharmacist calculates the CHA2DS2-VASc and HAS-BLED scores to determine eligibility and to initiate proper OAC in high-risk patients using a shared decisionmaking model. When OAC is prescribed, the ED pharmacist provides transitions of care services by expediting access to the medication, providing meds-to-bed service and post-discharge follow-up with assistance in scheduling post-discharge appointments with the specialists (eg, electrophysiologist and/or cardiologist). In the Baseline Group (n=99), 62.3% of patients with a moderate-high risk of stroke (CHA2DS2-VASc score ≥ 2) were discharged on guideline-based OAC therapy. In the Multidisciplinary Team Cohort group (physicians and pharmacist, n= 131), 87.8% of patients with a moderate-high risk of stroke were discharged on guideline-based OAC therapy, a 25.5% improvement in the treatment gap for appropriate anticoagulation in high-risk NVAF patients (p-value < 0.001, 95% CI (0.14-0.37)). This comparison is a combination of patients admitted through the ED and discharged home from the ED or from inpatient admission. Early identification and intervention of NVAF patients in the ED can significantly improve the percentage of high-risk patients that are discharged home with proper OAC. Although current guidelines do not clearly indicate the ED physician’s role in prescribing chronic OAC, our study demonstrates that a multidisciplinary shared decisionmaking model can successfully address the current treatment gap. We hope the results of our study will promote the implementation of this multidisciplinary model in EDs around the United States, as well as advocate for the American College of Cardiology to collaborate with ED organizations to create ED-specific guidelines for the management of atrial fibrillation.

Importance of short-term continuing care plan adherence on long-term outcomes among patients discharged from residential substance use treatment

ABSTRACTBackground: Patients adherent to their recommended treatment regimen demonstrate favorable outcomes. However, it is unclear whether there are specific short-term continuing care performance variables indicative of better long-term prognosis. Objective: This study determined the impact of attendance at an outpatient appointment within 7 days post-discharge from residential treatment on 12-month outcomes. Method: Data were abstracted from electronic medical records for 275 patients (58.9% male) discharged from a single residential treatment program. All discharge plans included a 7-day outpatient appointment with a provider in their home community. Patients were dichotomized based on their attendance at the initial appointment to yield a re-engagement variable. Twelve-month outcomes included past 30-day and continuous abstinence rates, quality of life, and long-term adherence to continuing care plans. Results: Patients attending their initial outpatient appointment within 7 days of discharge evidenced better long-term outcomes relative to patients who did not with respect to continuous abstinence (75.4% vs. 37.3%), past-30-day abstinence (92.0% vs. 70.6%), quality of life (94.2% vs. 78.4%), and adherence (66.4% vs. 9.8%). Re-engagement remained a significant predictor of continuous abstinence and quality of life at 12 months after controlling for 12-month adherence and relevant demographic characteristics. Conclusion: Treatment providers are encouraged to emphasize the relative importance of attending initial post-discharge appointments in achieving successful long-term outcomes. Allocation of resources to enhance engagement during residential treatment may be justified in that there may be value in actively encouraging patients to participate in continuing care activities, particularly shortly following discharge.

Correlates of keeping post-discharge appointments at a transitional care center: Implications for medical care disparities

Objective: Over the past decade, transitional care (TC) programs have demonstrated initial benefits for decreased care costs, reduced rehospitalizations and emergency department visits via care coordination team activities. Patients who completed their TC follow-up appointment subsequently have less frequent ER visits. The current study addressed correlates of missed appointments in a sample of under-investigated, mostly vulnerable (e.g., middle-aged, uninsured) patients.Methods: We conducted a retrospective observational study of an appointment database for patients enrolled at a major transition center during the first three years since its establishment in Northern Florida. Patients (n = 2,146) were referred to a Transitional Care Center (TCC) from a regional medical center after discharge. The type of insurance and demographic characteristics of the patients was used to predict missed appointments.Results: Logistic regression analyses indicated that privately insured patients were more likely and Black publicly and privately insured patients were less likely to keep first appointments. No effect on keeping appointments was seen for uninsured patients.Conclusions: Our findings suggest that an appointment referral is a necessary but not sufficient step for the accomplishment of TC goals. Medical teams need to collaborate with other health professionals, such as social workers, to identify the barriers to keeping appointments and ensure effective solutions for achieving the goal of preventing future ER visits and rehospitalization.