Does Scheduling a Postdischarge Visit with a Primary Care Physician Increase Rates of Follow-up and Decrease Readmissions?

Under the Hospital Readmission Reduction Program (HRRP), hospitals with higher than expected readmissions for select conditions receive a financial penalty. In 2017, hospitals were penalized a total of $528 million.^1,2 In an effort to deter readmissions, hospitals have focused on the transition from inpatient to outpatient care with particular emphasis on timely follow-up with a primary care physician (PCP).^3-7 Medicare has also introduced transitional care codes, which reimburse physicians for follow-up care after a hospitalization.

Most observational studies have found an association among patients discharged from the hospital between early follow-up with a PCP and fewer readmissions. One study found that patients without timely PCP follow-up after hospitalization on medical wards had a 10-fold increase in the likelihood of readmission.⁵ This association between early PCP follow-up and readmissions has been echoed in studies of all general admissions,⁵ as well as hospitalizations specific to heart failure,^7,8 chronic obstructive pulmonary disease,³ high-risk surgery,⁹ and sickle cell disease.¹⁰ One potential concern with this prior literature is that unmeasured patient characteristics might be confounders; for example, patients with more social support may be both more likely to have follow-up visits and less likely to have readmissions. Also, there are several studies showing no association between early PCP appointments and readmission rates.^6,9,11-13

Several prior interventional studies to improve the care transition from hospital to outpatient care have successfully deterred readmissions.¹⁴ In these trials, facilitating early PCP follow-up is just one component of a larger intervention,¹⁵ and a systemic review noted that the interventions were heterogeneous and often consisted of multiple complex steps.⁶ It is less clear whether interventions to facilitate early PCP follow-up alone are successful.

In this study, we evaluated the impact of an intervention that focused on facilitating early follow-up of PCPs. We assessed the impact of this intervention on the likelihood of having a PCP appointment within seven days of discharge and being readmitted within 30 days of discharge.

Postdischarge Appointment Service

In the fall of 2009, Beth Israel Deaconess introduced a postdischarge appointment intervention to facilitate follow-up with PCPs and specialty physicians after discharge from the hospital. Within the provider order entry system, attending and resident physicians enter a discharge appointment request for specified providers within and outside of the medical center and a specified time period. For example, a physician may enter a request to schedule a PCP appointment within 2-3, 4-8, 9-15, 16-30, or >30 days of discharge. Physicians are asked to submit this request on the day of discharge. The request is transmitted to dedicated staff (four full-time administrative staff and four part-time registered nurses) who verify the PCP, process the orders, and call the relevant practices to book the appointments. The date and time of the follow-up appointments are set without input from the patient. The details of the appointment, location, phone number of the clinic, and any other relevant instructions are automatically entered into the discharge instructions and discharge summary. The service is available Monday through Friday, and the turnaround on appointment creation is typically within one to three hours of the request. For patients who do not have a PCP or want to switch their PCP, the discharging physician can request a new PCP within the health system, and the service will schedule an appointment in this new PCP’s practice. Anecdotally, physicians are more likely to order the postdischarge appointment service for patients with more complex illnesses and longer lengths of stay and for those who come from underserved populations, as they perceive that it is more important for the patient to have this follow-up appointment, and/or the patient may have a harder time navigating the system and scheduling an appointment. Because of funding limitations, the hospital limited the intervention to hospitalizations on the general medicine and cardiology services. It was expanded in late 2011 to include the trauma surgery service.