Care coordination to target patient complexity and reduce disparities in primary care.

OBJECTIVE: The purpose of this study was to describe our Activation and Coordination Team (ACT) model for interprofessional care coordination in primary care and examine feasibility of using ACT medical and social complexity criteria to categorize patients into Quadrants that determine resource utilization. Research questions were: (a) Are there significant differences in demographic, medical, and social characteristics by Quadrant; (b) Do patients with combined high medical and social complexity differ from those with either high medical or social complexity; and (c) Is there an association between initial screening risk level and ACT Complexity Quadrant placement? DESIGN: Cross-sectional, descriptive. SAMPLE: Patients (N = 167) aged 18-65 enrolled in an urban Medicaid managed care network. MEASUREMENTS: Screening and comprehensive health risk assessment questionnaires and clinical data collection from electronic health records. RESULTS: Patient characteristics differed significantly by Quadrant. Combined medical and social complexity produced greater impact than additive effects. Patients who initially screened low risk nevertheless met ACT criteria for medical and/or social complexity. CONCLUSIONS: Greater effects for individuals with medical and social issues are due to interactions among factors. Traditional screening may miss patients with complex needs who need care coordination. Care coordination skills should be incorporated into population health curricula.

Efficacy of a Transition Clinic on Hospital Readmissions.

BACKGROUND: A primary care-staffed transition clinic is one potential strategy for reducing 30-day re-admissions for patients without an established primary care physician, but the effectiveness has not been studied. The objective was to test whether patients who completed a postdischarge transition clinic appointment were less likely to be readmitted within 30 days. METHODS: This retrospective cross-sectional study included adults with Medicare or Medicaid coverage who were discharged from general medicine units at Rush University Medical Center between October 2013 and October 2014. All patients had a follow-up appointment scheduled within 30 days of discharge in the transition clinic or with their primary care physician. A binary logistic regression model was constructed to test the relationship between 30-day readmission and follow-up appointment status, controlling for patient factors. RESULTS: The sample included 1149 patients with scheduled follow-up appointments (24% in the transition clinic and 76% with their primary care physician). After controlling for patient demographic characteristics and clinical factors, patients who did not complete a scheduled transition clinic appointment had approximately 3 times higher odds of readmission compared with patients who completed a transition clinic appointment (adjusted odds ratio, 2.80; P = .004). There was no significant difference in the likelihood of 30-day readmission between patients completing a transition clinic appointment and those who were scheduled with their primary care physician. CONCLUSIONS: A primary care-staffed transition clinic is a promising strategy for providing access after a recent hospitalization and effectively managing the initial posthospital discharge needs of vulnerable populations.