Stretching the end of hospitalization past discharge

A new clinic in an outpatient care center focuses on recently discharged patients at high risk for readmission.

Where: Eskenazi Health, a 315-bed hospital and associated health system in Indianapolis.

The issue: Reducing readmissions among high-risk patients.


“Like most health centers, [Eskenazi Hospital] already had many postdischarge interventions, but the readmission rate was still a little bit higher than desired,” said Kevin Tolliver, MD, FACP, formerly a hospitalist and now medical director of the primary care transitional care team at Eskenazi.

Hospital clinicians also had a pretty good idea of which patients were driving the elevated readmission rate—those without a primary care physician (PCP) or with a high LACE score (Length of stay, Acuity, Comorbidities, ED visits within 6 months). “They leave the door and you know there's a really good chance that they're going to come back,” said Dr. Tolliver. “What if we emphasized a more intensive postdischarge intervention for this group of patients?”

The intensive intervention chosen by Dr. Tolliver and colleagues was the Eskenazi Health Primary Care Transitional Care Practice, a new clinic in the hospital's outpatient care center that focuses on recently discharged patients.

How it works

On Oct. 1, 2015, the clinic began seeing patients who had been recently hospitalized and fell into either of the high-risk groups (no PCP or high LACE). Prior to discharge, the patients are scheduled for a follow-up appointment at the clinic, where they have a 30-minute visit with Dr. Tolliver and then see other staff members as needed.

“It's truly a multidisciplinary clinic in that we have pharmacy, a social worker, a diabetes educator, substance abuse counselors right there, so we can all take turns seeing the patients and tailor the visit to what they need,” Dr. Tolliver said. The clinic also has patient navigators who will find PCPs for patients who need them, as well as schedule future appointments with primary care or subspecialty physicians.

The intent of the clinic is to serve as a bridge to outpatient care. “We don't try to address any kind of long-term problem that the PCP would be better suited to address. We review with the patients why they were in the hospital, what happened during their stay, and what still needs to happen. [We] make sure they're getting to where they need to, are on their meds, etc., and then we get them in with their PCP for long-term care,” said Dr. Tolliver. “They may have been discharged 3 days ago and they come in and the wheels are already falling off, and you're able to make interventions.”

The majority of patients are seen at the clinic only once after discharge, although a few with particularly complex needs may have a second or third visit.


To determine whether the clinic was accomplishing its goal of reducing readmissions, Dr. Tolliver compared the 459 patients he saw between the clinic's opening and Jan. 30, 2016, to the 284 patients who were referred to the clinic but didn't show up for their appointments.

“The patients who I actually saw had a 30-day readmission rate of 13.9% and the group of patients who qualified—people who were just as sick that didn't show up—had a readmission rate of 21.8%. We were really excited to see what we're doing did make an impact,” said Dr. Tolliver.

The clinic's readmission rate was also lower than the hospital's overall rate of 14.8%, an achievement considering that the clinic's patients had been chosen because of their high expected risk of readmission, Dr. Tolliver noted.


As the method of analysis suggests, the clinic's main challenge was the no-show rate, which started around 40%. To reduce that number, Dr. Tolliver began visiting patients before discharge, explaining the clinic and its purpose. “That's helped the no-show rate some,” he said, noting that the rate is now around 30%.

“The other barrier is just trying to get buy-in from as many PCPs as we can,” said Dr. Tolliver. “There are some who understandably would still just prefer to see their patients postdischarge and not have this extra step, so for PCPs who are adamant about that, we honor that.” To other physicians, however, he explains the clinic's purpose and setup. “I tell them our clinic is set up to be conducive to hospital follow-up visits, with adequate time with each patient and multidisciplinary support.”

The clinic is financially supported by the hospital, so the staff members don't have to rush through visits to maximize productivity like many outpatient practices. “We're trying to take these high utilizers of the system and dedicate some resources to them to try to save money and provide better quality of care in the long run,” Dr. Tolliver said. “Once the PCPs understand what we're doing and maybe more importantly what we're not trying to do...most of them understand and a lot of them are even very appreciative.”

How patients benefit

“The patients truly really enjoy it,” said Dr. Tolliver. “They encounter various roadblocks in the health care system, so the fact that we have somebody who is there to jump in and help them get their meds or get transportation makes the patients come away feeling like they got even better care and they feel better about their overall health and recovery process.”

Hospitalists also appreciate the clinic's presence, according to Dr. Tolliver. “If the inpatient teams have a patient that they're a little worried about, I think they feel immensely more comfortable letting them go, knowing that they're going to be seen in our clinic,” he said.

Next steps

The clinic is continuing to focus on its no-show rate, looking for interventions to further reduce the problem. “We're hoping to get it under 20%,” said Dr. Tolliver.

Words of wisdom

“You think that the end of the inpatient stay is when the patient walks out of the hospital. We're starting to rethink that....There's so much that happens between when a patient leaves the hospital and that first visit...if they leave and they can't get their medicine or are confused about what to do, all of that hard work can be very quickly forgotten,” said Dr. Tolliver.