Transitional Care Management care team impact on no-show rates to hospital discharge appointments

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. The pre-intervention no-show rate of TCM appointments at Wellstar MCG Health was 44% per month.

Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

Study Design and Analysis: No-show rates were captured as a percentage per month for a three-month time frame after the intervention was begun. The no-show rate for each month after the intervention was compared to the corresponding calendar month of the previous year.

Setting: Wellstar MCG Health is a 520-bed tertiary hospital with a Family Medicine inpatient service and an attached Family Medicine resident continuity clinic.

Population Studied: Inpatients were referred if they were being discharged from the Family Medicine service to home. Referrals were not placed for patients being discharged to another facility or who already had an outside primary care provider.

Intervention: A team was created with an attending physician, care coordinators, and front office staff. A referral order was created in the hospital system’s electronic health record to the “Hospital Discharge Clinic,” and referrals were placed for urgent (7-day) or routine (14-day) TCM appointments. The care coordinator then attempted to call the patients on 3 consecutive days after discharge to make an appointment with either the patient’s PCP or an APP.

Outcome Measures: The quantitative outcome measured was the difference between TCM clinic no-show rates before and after the intervention began.

Results: The no-show rate to TCM appointments was 44% prior to the intervention. In the three months (January 2024-March 2024) after implementation, the no-show rates to TCM appointments were 15%, 12%, and 15% respectively, a statistically significant decrease (p-value 0.0011).

Conclusions: A TCM clinic team with a dedicated care coordinator to help hospital discharge patients set up TCM visits significantly decreased the TCM appointment no-show rate in a Family Medicine resident clinic. It also decreased readmission rates and saved hundreds of thousands of dollars in healthcare expenses. For patients, timely follow-up in a primary care office can improve health literacy and decrease need for readmission. Additionally, decreased no-show rates provide for better resident learning and experience.