Outpatient providers need better care transitions, too

Care transitions are often depicted as a patient's move out of the hospital and to the next destination, such as a post-acute care facility or back home. Far less attention is paid to other transitions in healthcare that quietly shape a patient's health outcomes.

The 22 outpatient clinics in the Montefiore Medical Group in New York's Bronx and Westchester counties have focused on seemingly simple, often overlooked care transitions. In the past two or three years, “we've really hardwired this process,” said Namita Azad, the group's transformation manager.

They focus on four transitions: emergency room or inpatient settings to outpatient providers, pediatric to adult, referrals between disciplines, and the addition of new patients.

Paving the path for a teenager to go from seeing a pediatrician to seeing an adult practitioner, or to ensure that a patient who is referred from a primary-care provider to a specialist, has required careful communication and a multidisciplinary approach. Clinics, which include pediatric care, internal medicine and family medicine, also have a social worker, psychologist or psychiatrist, and a referral coordinator

“For the most part, we're touching the entire lifespan for our patients,” Azad said. “We're taking care of the whole patient.” Their successes register in improved visitor volume and retention, as well as improvements in clinical metrics, such as depression screening, she added.

The proportion of patients screened for depression used to be in the 60% range, Azad said. Now it's about 90%. Azad attributed that awareness directly to having behavioral health staff in the same location with primary-care providers

Building this infrastructure has not merely ensured continuity of care. It has also allowed Montefiore's outpatient providers to branch out and talk to patients about nonmedical issues that affect health, such as environmental or socio-economic stressors.

The standard time for a patient to switch from seeing a pediatrician to a physician who sees adults, such as a family doctor, is around age 17. But at Montefiore, providers start the conversation years before, around the age of 13 or 14. The pediatrician will start to have confidential visits with the teenager to help wean them from their parents (or, perhaps, wean parents from their children).

“You talk to the patient and you say, 'Listen, you're of a certain age now, and to better take care of all your health needs, there's a better-suited professional within this building you'll go to in the future,' ” Azad explained. When the time comes to switch doctors, the handoff is sometimes literal. The pediatricians “physically walk that patient to the internal medicine provider,” she said. That way, patients feel they can trust their new doctor.

When a patient is discharged from the emergency department, the use of the same electronic health record system in the ED and at outpatient clinics—the Montefiore system uses one from Epic Systems Corp.—smooths the transition. It's hard-wired to ensure that someone reaches out to patients within 48 hours to make sure they have everything needed and to schedule a follow-up visit with a primary-care provider within a week to 10 days.

Azad said their success rate of reaching patients within two days was at least 95%. The clinics also closely track patients when providers refer them to clinical specialists or other resources, such as a community-based organization. If a patient is referred to a specialist, such as a cardiologist or a health educator, the referral is marked in the EHR. Referral coordinators follow up with and help patients with challenges they encounter navigating the healthcare system.

Developing these transitional best practices now is critical. Transitions will become only more important in the outpatient realm, according to Dr. Noel Brown, director of performance and quality improvement at Montefiore Medical Group. The growth of value-based payment programs that aim to reduce unnecessary hospital readmissions has increased the incentive to keep patients out of the hospital and put more pressure on the outpatient realm.

“We're seeing a shift where resources need to be allocated to the outpatient environment, more so than in the past,” Brown said. “We're being asked to address more issues.”

The attention to care transitions is part of a systemwide shift to provide patient-centered care. The Montefiore Medical Group is certified by the National Committee for Quality Assurance as a patient-centered medical home, a designation both Brown and Azad said has been vital in aligning payments with Montefiore's patient-centered services.