Early research we conducted as a member of Center Surgical Outcomes and Quality and an American College of Surgeons-sponsored RWJ Clinical Scholar nearly 15 years ago was focused on understanding the causes of hospital readmissions.
Fast-forward, we at HubMD now address one of the factors thought to contribute to readmissions- discontinuity of care, especially specialty care follow-up- through our Virtual Post-Discharge Clinical Transitions program.
Focusing initially on patients who have needs for mental health and substance use disorder services, we have learned many important lessons:
1. Connecting with patients takes time and trust. (And often many failed attempts!)
2. Stakeholder engagement with hospital leadership and emergency department physicians is crucial
3. A comprehensive care team matters as patients barriers to post discharge specialty care access vary (e.g., confirming insurance status, appointment making, arranging transportation, clinical assessments, information gathering in abscence of HIEs, etc.)
4. Sharing data and simplifying tech use is key.
As we expand to addressing the post-discharge transitional care needs for other at-risk specialties and conditons, we believe we are on a path addressing yet another gap. Patients who have seen a surgeon or cardiologist shouldn't have to go back to their pcp after being told by a hospital-based specialist that additional specialty care follow up and intervention is needed.
Yet, for many medicaid patients, that's exactly what happens.
It needs to change. And it can. William Jih, M.D., M.B.A. and his team working with HubMD is making that change happen in the Inland Empire.
Registered Occupational Therapist, Bathroom Mobility , Private Duty Health Services, Licensed Life and Health Insurance Agent ( Licensed in FL, GA, TX, TN, OH, MI, SC)
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