Partnering with outpatient providers to identify gaps in patient care

3 minute read

Partnering with outpatient providers to identify gaps in patient care

< 1 minute read

St. Mary’s developed and maintains ongoing relationships with outpatient providers to quickly address any issues that arise.

The Issue

When looking at our readmissions, we realized there were gaps in patient care when we discharged patients to outpatient facilities like SNFs, home care, and long term care facilities. One example: we didn’t know that one of our local SNFs didn’t have a pharmacy in-house. We discharged patients to them regularly without medication, always assuming they could fill a prescription upon arrival. This gap in care was potentially the cause of readmissions, especially if patients were discharged in the evening or on weekends when pharmacies were closed.


St. Mary’s Medical Center is a non-profit teaching hospital in San Francisco, CA. It has 300 beds and serves a primarily elderly Medicare population with multiple comorbidities. Their transitions program began in 2009 and is influenced by Project RED and IHI’s Transforming Care at the Bedside.

What We Tried

First we went out to many of our local outpatient facilities to introduce our program and ourselves. Then we invited all of them back to St. Mary’s for quarterly meetings. At those meetings we would review the return-to-acute-care numbers and address any concerns that we, or the facilities, were having. Issues mostly focused on information needs at transitions (i.e. what do we need from them when patients are sent back to the ED and what do they need from us when we discharge a patient to them), but we also discuss more general topics like med rec and working with patient families.

Around 30 people attend each quarter and they range from directors to nurses, case manager, and social workers. We intentionally invite all the different types of providers at the same time, rather than having one meeting for SNFs and another for home health agencies, because we all face similar challenges when working with patients and it helps to have multiple perspectives in the room.


The relationships we have built with our community partners have really strengthened our program. They know who we are, we know who they are, and we know whom to call if there’s a problem. We had a patient who returned to acute from a SNF without their medication list. They were in the ICU and really needed to know what medication the patient was taking to make their plan of care. In the past this would have taken hours as we waited for the SNF to find the care team, look into the chart, and get back to us. Our transitions team knew exactly who to call and had the information in the chart within 15 minutes.

Regular meetings also surface challenges quickly so that both sides can work on addressing them. At these meetings we learned that the outpatient providers had a lot of difficulty reaching care teams at the hospital. We changed our procedures on this end and now everyone says it’s almost never a problem getting in touch with someone at the hospital.

Additional Benefits

This regular communication is also good for the outpatient providers. We have four home care agencies in our community—they had never spoken with each other before our meetings. At these meetings everyone realized they had a lot to learn from each other and could work together to improve care for patients.


All of the agencies were open to the idea of collaborating. All we had to do was invite them. And give them free food.

Organizational Background

Location: 450 Stanyan Street, San Francisco, CA, United States

Organization Type: Hospital