Postdischarge clinics and hospitalists: A review of the evidence and existing models

Readmission prevention is paramount for hospitals and, by extension, hospitalist programs. Hospitalists see early and reliable outpatient follow-up as a safe landing for their most complicated patient cases. The option of a postdischarge clinic arises from the challenge to arrange adequate postdischarge care for patients who lack easy access because of insurance or provider availability. Guaranteeing postdischarge access by opening a dedicated, hospitalist-led postdischarge clinic appears to be an easy solution, but it is a solution that requires significant investment (including investment in physician and staff training and administrative support) and careful navigation of existing primary care relationships. In addition, a clinic staffed only with physicians may not be well equipped to address the complex social factors in healthcare utilization and readmission. Better understanding of the evidence supporting post discharge physician visits, several models of clinics, and the key operational questions are essential to address before crossing the inpatient-outpatient divide.

A postdischarge outpatient provider visit is often seen as a key factor in reducing readmissions. In 2013, Medicare added strength to this association by establishing transitional care management codes, which provide enhanced reimbursement to providers for a visit within 7 or 14 days of discharge, with focused attention on transitional issues.¹ However, whether a postdischarge visit reduces readmissions remains unclear. Given evidence that higher primary care density is associated with lower healthcare utilization,² CMS’s financial investment in incentivizing post discharge physician visits may be a good bet. On the other hand, simply having a primary care physician (PCP) may be a risk factor for readmission. This association suggests that postdischarge vigilance leads to identification of medical problems that lead to rehospitalization.³ This uncertainty is not resolved in systematic reviews of readmission reduction initiatives, which were not focused solely on the impact of a physician visit.^4,5

The earliest study of postdischarge visits in a general medical population found an association between intensive outpatient follow-up by new providers in a Veterans Affairs population and an increase in hospital readmissions.⁶ This model is similar to some hospitalist models for postdischarge clinics, as the visit was with a noncontinuity provider. The largest recent study, of patients hospitalized with acute myocardial infarction, community-acquired pneumonia, or congestive heart failure (CHF) between 2009 and 2012, found increased frequency of postdischarge follow-up but no concomitant reduction in readmissions.⁷ Although small observational studies⁸ have found a postdischarge primary care visit may reduce the risk for readmission in general medical patients, the bulk of the recent data is negative.

In high-risk patients, however, there may be a clear benefit to postdischarge follow-up. In a North Carolina Medicaid population, a physician visit after discharge was associated with fewer readmissions among high-risk patients, but not among lower risk patients, whose readmission rates were low to start.⁹ The results of that study support the idea that risk stratification may identify patients who can benefit from more intensive outpatient follow-up. In general medical populations, existing studies may suffer from an absence of adequate risk assessment.

The evidence in specific disease states may show a clearer association between a postdischarge physician visit and reduced risk for readmission. One quarter of patients with CHF are rehospitalized within 30 days of discharge.¹⁰ In this disease with frequent exacerbations, a clinic visit to monitor volume status, weight, and medication adherence might reduce the frequency of readmissions or prolong the interval between rehospitalizations. A large observational study observed that earlier post discharge follow up by a cardiologist or a PCP was associated with lower risk of readmission, but only in the quintile with the closest follow-up. In addition, fewer than 40% of patients in this group had a visit within 7 days.¹¹ In another heart failure population, follow-up with either a PCP or cardiologist within 7 days of discharge was again associated with lower risk for readmission.¹² Thus, data suggest a protective effect of postdischarge visits in CHF patients, in contrast to a general medical population. Patients with end-stage renal disease may also fit in this group protected by a postdischarge physician visit, as 1 additional visit within the month after discharge was estimated to reduce rehospitalizations and produce significant cost savings.¹³

With other specific discharge diagnoses, results are varied. Two small observational studies in chronic obstructive pulmonary disease had conflicting results—one found a modest reduction in readmission and emergency department (ED) visits for patients seen by a PCP or pulmonologist within 30 days of discharge,¹⁴ and the other found no effect on readmissions but an associated reduction in mortality.¹⁵ More data are needed to clarify further the interaction of postdischarge visits with mortality, but the association between postdischarge physician visits and readmission reduction is controversial for patients with chronic obstructive pulmonary disease.

Finally, the evidence for dedicated postdischarge clinics is even more limited. A study of a hospitalist-led postdischarge clinic in a Veterans Affairs hospital found reduced length of stay and earlier postdischarge follow-up in a postdischarge clinic, but no effect on readmissions.¹⁶ Other studies have found earlier postdischarge follow-up with dedicated discharge clinics but have not evaluated readmission rates specifically.¹⁷In summary, the effect of postdischarge visits on risk for readmission is an area of active research, but remains unclear. The data reviewed suggest a benefit for the highest risk patients, specifically those with severe chronic illness, or those deemed high-risk with a readmission tool.⁹ At present, because physicians cannot accurately predict which patients will be readmitted,¹⁸ discharging physicians often take a broad approach and schedule outpatient visits for all patients. As readmission tools are further refined, the group of patients who will benefit from postdischarge care will be easier to identify, and a benefit to postdischarge visits may be seen

It is also important to note that this review emphasizes the physician visit and its potential impact on readmissions. Socioeconomic causes are increasingly being recognized as driving readmissions and other utilization.¹⁹ Whether an isolated physician visit is sufficient to prevent readmissions for patients with nonmedical drivers of healthcare utilization is unclear. For those patients, a discharge visit likely is a necessary component of a readmission reduction strategy for high-risk patients, but may be insufficient for patients who require not just an isolated visit but rather a more integrated and comprehensive care program.^8,20,21