Introduction: Hospital readmission is costly, in both patient quality of life and healthcare expenditures. Timely post-discharge follow-up has shown to reduce preventable readmissions. Efforts should be aimed at improving coordination of follow-ups. The aim of this quality improvement project was to increase post-hospital discharge follow-up by 20% for academic primary care patients admitted to a local tertiary care hospital by June 2020. This QI project was conducted at St. John Medical Center and the OU Internal Medicine Clinic utilizing Plan-Do-Study-Act methodology (PDSA). Patients admitted to OU inpatient teams who also designated OU Internal Medicine as their PCP were included in the study. An EMR query was utilized to measure follow-ups completed within 14 days of discharge. A process map was made, showing intervention points. Gap Analysis/Scatter Diagram was used to show points of largest impact.

Methods: PDSA #1: Senior residents were given access to AllScripts (the clinic EMR scheduling program) to directly schedule patient follow-up appointments within 14 days of discharge. Follow-up appointments were included in patients’ discharge paperwork.    PDSA #2: Prior to discharge, patients were screened by care managers for a follow-up home visit. If appropriate, a multidisciplinary team of providers conducted an onsite follow-up visit within 14 days of discharge.

Results: After PDSA #1: Residents surveyed after the first PDSA cycle admitted feeling overwhelmed with additional tasks and inconsistently scheduled appointments in AllScripts. In addition, EMR review demonstrated a high no-show rate for patients with follow-up appointments. Due to these results, we sought alternative options.

After PDSA #2: Three patients were visited in their homes for an onsite 14-day follow-up appointment. Unfortunately, this process was put on hold given the COVID outbreak.

At baseline, 31.6% of patients discharged from the hospital attended post-discharge follow-up visit within 14 days. This percentage declined to 29.2% after our interventions.

Conclusion: The low rate of hospital discharge appointments within two weeks of discharge indicates that many patients are lacking crucial follow-up care. This project found that having residents enter appointments directly into AllScripts and performing home visits within 14 days of discharge made no difference in the overall rate of successful post-discharge follow-up visits. Weaknesses of this study include but are not limited to the gap of data between July 2019 and March 2020 and the small number of home visits that were performed. This project confirms the concern that unless new approaches to significant post-discharge follow-up barriers are considered, increasing the percentage of successful follow-up appointments will remain a difficult task.