Standardizing post-discharge care at one of the University of North Carolina Hospitals clinics cut readmissions by 65 percent, according to a study published in the Journal of General Internal Medicine.

In addition, the study found that one 30-day readmission is avoided for every seven patients cared for under the new program.

The study evaluated a new program created by the Internal Medicine Clinic at UNC Hospitals for patients recently been discharged from the hospital. The program includes identification of patients who have been discharged, a process for contacting patients after hospital discharge via a dedicated care manager, and standardization of the hospital follow-up appointment content. The hospital follow-up appointments are with a clinical pharmacist practitioner and a physician.

The program was evaluated by comparing readmission rates of UNC Internal Medicine Clinic patients seen in the hospital follow-up clinic to those who did not receive the enhanced services. Patients in both groups were discharged from the hospital in the same month and were selected at random. The study evaluated hospital readmission at 30 and 90 days as well as emergency department utilization, and found striking reductions: twenty-four patients in the control group were either readmitted or visited the ED within 30 days, compared to 10 patients in the program.

The study team also found that frequent small-scale process evaluation and adjustments were required to optimize the program. For example, to reduce clinic visit duration and heterogeneity between visits, a patient intake questionnaire and note template were developed, the importance of phone reminders was reinfiorced, and phone scripts refined.

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