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Implementing Posthospital Interprofessional Care Team Visits to Improve Care Transitions and Decrease Hospital Readmission Rates

Baldwin, Stacy M., DNP, FNP-BC; Zook, Sharon, DNP, FNP-BC; Sanford, Julie, DNS, RN, FAAN

doi: 10.1097/NCM.0000000000000284

Purpose/Objectives: Today's health care climate is composed of patients who experience complex conditions with multiple comorbidities, requiring higher utilization of acute care services. It is imperative for acute care and primary care landscapes to bridge silos and form collaborative relationships to ensure safe and effective transitions of care from hospital to home. An interprofessional, posthospital follow-up clinic (Discharge Clinic) is one approach that can be used to improve transitions of care and decrease preventable hospital readmissions. The purpose of the Discharge Clinic is to improve transitions of care and decrease 30-day hospital readmission rates. The clinic's objective is to utilize an interprofessional care team to improve transitions of care posthospital, for complex care patients.

Primary Practice Setting: The posthospital Discharge Clinic is an innovative, interprofessional clinic located in a large western state that was initiated to improve transitions of care for its patients discharged from an acute care setting. The interprofessional care team consists of a certified family nurse practitioner, a clinical pharmacist, a nurse case manager, and a social worker.

Findings/Conclusions: In 2013, Medicare and private coverage data reveal 30-day readmission rates of 17.3% and 8.6%, respectively (Agency for Health Care Quality and Research, 2013). From February 2016 to September 2016, Discharge Clinic project participants achieved a 30-day readmission rate of 2.7%. The Discharge Clinic enrolled 75 patients in the project (n = 75). The 30-day readmission rate achieved by the Discharge Clinic represents a significant decrease compared with national benchmark data. Two patients enrolled in the project were readmitted within 30 days of hospital discharge. For fiscal year 2015, the medical group's estimated cost of readmissions was $7,156,800 and 30-day all-cause readmission rate was 12.3%. This equated to the Discharge Clinic's estimated impact in reducing readmissions at 9.63% and an estimated savings of $689,199.84. The Discharge Clinic estimated its operating costs at $354,000, which gave a total estimated net savings of $335,199.84.

Implications for Case Management Practice: The current health care landscape is composed of an aging population, rising in complexity. New approaches are needed to bridge gaps between acute care and primary care settings. The Discharge Clinic serves as an innovative model that health systems throughout the country can replicate to improve transitions of care for complex patients. The interprofessional care team model can be implemented to advance and bridge the management of acute and ambulatory care patient populations.

Stacy M. Baldwin, DNP, FNP-BC, is the Doctor of Nursing Practice for Charter Health Care Group in Rancho Cucamonga, California. She received her DNP from James Madison University and her Bachelor's and Master's degrees specializing as a family nurse practitioner from the Virginia Commonwealth University School of Nursing. She has over 10 years of experience in management of chronic disease populations and in implementing transitional care models for high-risk patients. As a Lean Six-Sigma Greenbelt, she has vast experience in clinical innovation and has presented her work at local, state, and national health care conferences.

Sharon Zook, DNP, FNP-BC, is a professor in the School of Nursing and Graduate School at James Madison University. She has over 30 years of teaching experience, with 12 at the graduate level. She has participated in funded research and has presented and published on teaching pedagogies, international education and chronic illness management. Her clinical expertise is chronic illness self-care and management. She is licensed as a Master Trainer for the Chronic Disease Self-Management and Diabetes Self-Management Program out of Stanford University. Dr Zook has conducted numerous client and leader trainings.

Julie Sanford, DNS, RN, FAAN, is a professor and Director of the School of Nursing at James Madison University. She has published and presented in the areas of interprofessional education and collaborative practice, health policy, informal caregiving, and the scholarship of teaching and learning. She has taught at all levels of nursing education and obtained HRSA funding to lead development of one of the first BSN to DNP adult gerontological acute care NP programs in the country. She became a fellow in the American Academy of Nursing in 2017 and has served as the Director at JMU since 2011. She is a graduate of the University of Alabama, University of South Alabama and LSU Health Science Center.

Address correspondence to Stacy M. Baldwin, DNP, FNP-BC, School of Nursing, James Madison University, MSC 4305 HBS Bldg, 235 Martin Luther King Jr. Way, Harrisonburg, VA 22807 (

The authors report no conflicts of interest.

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