A new service to support post-hospital patients

Parkview Health recently introduced a new Discharge Clinic, located in Parkview Regional Medical Center (PRMC). Lisa Knox, MPH, supervisor, Ambulatory Care Transitions Coordination, Parkview Population Health, and Martha Bushman, MS, RN, manager, Ambulatory Care Transitions Coordination, outline the role of this new clinic and how it supports the patient care journey.

What was the motivation for developing the Discharge Clinic?

We identified a significant volume of patients who were subject to “falling through the cracks” post-hospital discharge. These are patients who have a variety of needs, both clinical and social-based, who are not established with a primary care provider (PCP) and thus may not have the follow-up support that is needed to set them up for success once they have been discharged from the hospital.

We intend for the clinic to serve as a viable resource for these patients. We also hope it promotes improved access for patients who might be established with a PCP, but who require a post-discharge follow-up appointment sooner than their PCP has available appointments. 

How does the Discharge Clinic work?

Patients have an extended comprehensive visit with a physician and a clinical pharmacist. If the providers identify clinical needs during the visit, a registered nurse is available to see the patient. If they identify social-based needs, a social support specialist is available to see the patient.

Where is the Discharge Clinic located?

The clinic is located within Parkview’s Welcome Clinic at PRMC, Entrance 11, Suite 020 (just to the left of the Outpatient Pharmacy).

Who can patients expect to see in the clinic?

Reena Thapa, MD, serves as the clinic’s provider. The Discharge Clinic team also includes a pharmacist, nurse care coordinator and social support specialist.

Who would be a good candidate to utilize the Discharge Clinic?

Patients who are presently inpatient at PRMC who do not have a PCP, or who have a PCP but the length of time before a post-discharge follow-up office visit could be scheduled for the patient exceeds the amount of time with which the discharging hospital provider is comfortable.

This service also applies to patients who are identified as being at high-risk for readmission and patients who are discharging home without a referral for home healthcare services (i.e., without the additional support that HHC can provide to patients’ post-hospital discharge).

What are the benefits for the patient?

The Discharge Clinic offers patients the opportunity for comprehensive follow-up after they’ve been discharged from the hospital, which includes access to the clinic’s provider, pharmacist, nurse care coordinator and social support specialist. One important aspect of this visit, is the thorough medication reconciliation completed between the patient and the clinic’s pharmacist.

One of the clinic’s goals is to facilitate getting patients scheduled for a new patient appointment with a PCP before they leave the Discharge Clinic appointment.

What are the benefits for the caregivers?

Inpatient hospital care givers can have more confidence discharging patients with the assurance that they will have close clinical follow-up after discharge. Because outpatient caregivers have a comprehensive assessment for each patient, they can continue to work to ensure all needs are met. This has a greater impact in preventing avoidable complications or additional medical needs.

How will this impact the patient’s success in the long run?

It is our hope that the patient feels more connected with the health system, and therefore become more empowered to navigate their healthcare. The primary objective of this new service is to provide a patient-centered approach to each patient’s individual health journey.

 

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