Some of The Vancouver Clinic’s chronically ill patients who are at high risk for hospital readmissions are now able to receive intensive follow-up care through a new program at the 87th Avenue medical office.
Six weeks ago, The Vancouver Clinic launched its new Transitional Care Clinic, which provides intensive, multi-disciplinary follow-up care immediately following a patient’s hospital discharge. The goal is to reduce the number of hospital readmissions and improve the overall health of patients, said Dr. Joan Hunter, a hospitalist and the new clinic’s launch coordinator.
“It benefits our patients to stay out of the hospital. It benefits the system as a whole,” Hunter said. “If we offer the services now, our patients will benefit in the long term.”
The clinic is aimed at patients with two or more high-risk, chronic medical conditions — such as heart failure, coronary artery disease or chronic obstructive pulmonary disease — with recent hospital admissions. Patients with active medical problems involving different organ systems often leave the hospital with a lot of information, medication and directions for follow-up care, Hunter said.
“Things fall through the cracks, especially upon hospital discharge,” Hunter said. “We’re trying to identify patients who can benefit from more intensive care.”
The Vancouver Clinic has hospitalists — physicians who work in the hospital — at both PeaceHealth Southwest Medical Center and Legacy Salmon Creek Medical Center. The hospitalists can refer eligible patients to the Transitional Care Clinic upon hospital discharge.
At the new clinic, patients each will undergo a two-hour appointment, during which they will meet with a hospitalist for a thorough review of medications and symptoms and receive a full physical exam.
Patients then will meet with a nurse case manager and a medical social worker who can help address barriers to maintaining optimal health, such as transportation challenges that cause patients to miss doctor appointments, and get patients signed up for home health services, if necessary.
Finally, patients will meet with a dietitian and a pharmacist. The pharmacist creates a seven-day pill set for patients and a grid that describes each medication and required doses — something particularly helpful for people taking multiple drugs, Hunter said.
“A lot of patients have identified that as a big benefit,” she said.
After the first lengthy visit, patients will see the team of providers once a week — more, if necessary — for about a month. The subsequent visits are one hour.
The goal is to address any problems and symptoms before they progress to the point of requiring an emergency department visit or hospital readmission, Hunter said.
“If somebody’s going to readmit to the hospital, it’s going to be in the first two weeks (of discharge),” she said.
And so far, the new clinic is enjoying some success.
The clinic has 15 active patients and only two readmissions since the program began. Clinic staff estimate they’ve prevented at least five hospital readmissions, Hunter said.
The Transitional Care Clinic operates on Mondays, Wednesdays and Fridays and has the ability to see three new patients and three returning patients each day. The Vancouver Clinic hopes to expand to five or six days, including Saturdays, as the patient base grows in the next year, Hunter said.
