Some hospitals are trying a new strategy to interrupt this predictable and pricey pattern: post-discharge clinics. These hospitals are identifying patients who are more likely to have trouble after discharge, either because of their medical conditions or because they lack health insurance or a primary-care provider, and funneling them to the clinic where they receive one-on-one assistance.
Deloris Eason, 64, was discharged from Boston’s Beth Israel Deaconess Medical Center earlier in December, after having been treated for severe stomach cramps, diarrhea and vomiting. Clinicians weren’t sure whether she had had a bad case of food poisoning or colitis, an inflammation of the colon. Because her primary-care physician couldn’t see her until mid-January, hospital staff referred her to the post-discharge clinic.
By the time she came in four days after leaving the hospital, Eason was feeling better but was concerned because she hadn’t had a bowel movement since returning home. The practitioner at the clinic told her to give it another day and then take a laxative. If that didn’t work, she was instructed to come back.
“I had a chance to ask questions I didn’t get to ask at the hospital,” Eason says, “key questions that came up after I got home.”
The doctor also checked that she was following the diet she had been given and was taking her antibiotics, and made follow-up appointments for her with a gastroenterologist and her primary-care provider.
The clinic helps streamline the process of getting patients in to see their primary-care physicians, says its medical director, Lauren Doctoroff.
A typical patient visits Beth Israel’s post-discharge clinic, located near the hospital, just once or twice. But treatment may last longer at post-discharge clinics affiliated with safety-net hospitals that serve large numbers of low-income, uninsured and other vulnerable patients.
One such hospital is Tallahassee Memorial HealthCare’s Transition Center. Clinicians say they see most patients for up to two months and will extend that time frame if necessary.
“We’re a bridge until we are guaranteed they are in . . . primary care,” says Dean Watson, Tallahassee Memorial’s chief medical officer.
The center targets patients at high risk for readmission, including the uninsured, those who don’t have a primary-care physician or who can’t get an appointment with their doctor within a week of discharge, and patients who have been admitted at least three times in the past year.
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