SF General sends a letter to outpatient clinics when their patients are readmitted, and shares risk factors they’ve discovered for that patient.
Collaborator (Non-Members)Larissa Thomas, Michelle Schneidermann
We realized that no matter how much we do, patients only spend 3-4 days at the hospital and the rest of their time outside of it. We were learning a lot about patients’ living situations and domains of risk from our conversations with them, but we didn’t share any of this information with their outpatient providers after discharge.
San Francisco General is a non-profit hospital and level 1 trauma center in San Francisco, CA. It has 598 beds and serves a diverse population, the majority of whom are lower income and do not speak English as their first language. Many are also illiterate in English as well as their preferred language. The hospital also serves individuals who may not have health coverage, housing or access to food. They enroll the most difficult to engage patients who have a history of substance abuse and poor health outcomes. Their transitions program began in 2009 and is influenced by the Care Transitions Program and Project RED.
What We Tried
We started with the outpatient clinics—there are around 22 in our community. We reached out to them to see what their challenges were regarding readmissions and what they needed from us. Now, when a patient is enrolled, we learn about their needs and concerns and send their primary care physician a letter with their domains of risk. “Mr. Jones has been readmitted for congestive heart failure. We’ve learned that transportation is one of his domains of risk. He hasn’t been going to his follow up appointments because he can barely walk. Perhaps the clinic can help get paratransit support for Mr. Jones.” The domains of risk are any red flags we uncovered from our conversations, for example transportation, lack of support at home, or managing multiple medications that they can’t afford.
We used to send letters to outpatient clinics notifying that their patient was admitted and with which diagnosis. Sometimes doctors would ask us why we were sending them this information—they already knew what conditions their patients had. Now we get letters from the doctors thanking us for letting them know about these other factors related to their patients’ health.
These letters were the first step in developing stronger relationships with outpatient clinics. Now that we’ve established this communication pathway, we can easily bring up other questions or concerns we have. It also makes it easier for patients to schedule follow up appointments because their primary care physicians are already aware that they have been in the hospital.
It’s about collaboration, so it was really important for us to go out to the clinics and ask them what they need. If we had just started sending them information they wouldn’t have been as receptive to it.