Development of a Primary Care Transitions Clinic in an Academic Medical Center.

INTRODUCTION: Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status. AIM: To describe and evaluate a primary care transitions clinic that serves patients with medical and/or social needs that must be addressed prior to establishment of primary care. SETTING: Brigham Health, an academic medical center in Boston, MA. PROGRAM DESCRIPTION: The transitions clinic opened within an existing primary care practice in January 2019. It employs one full-time nurse care coordinator and one full-time medical assistant, and is staffed by one primary care physician (PCP) or nurse practitioner each weekday afternoon. Both medical and social diagnoses that require follow-up post-discharge are addressed. Patients with any insurance are seen as many times as necessary until PCP care is established. PROGRAM EVALUATION: In the year after its establishment (January 20, 2019, to January 19, 2020), the transitions clinic received 498 referrals (73.2% from the emergency department (ED), 23.3% from inpatient), with 207 patients ultimately seen. Patients were seen 5 (median; IQR 4-6) work days post-discharge, with 2 (median; IQR 1-3) visits per patient. Patients seen in the transitions clinic had significantly fewer ED visits than a comparator cohort referred to Brigham Health Primary Care after ED or hospital discharge in the year prior (January 20, 2018, to January 20, 2019). Patients seen in the transitions clinic additionally had significantly fewer ED visits and hospitalizations in the three months post-referral than in the three months pre-referral. The most common social determinants addressed by the clinic's nurse coordinator were insurance, transportation, and housing. DISCUSSION: A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic.

Behavioral health integration in primary care at Brigham and Women׳s Advanced Primary Care Associates, South Huntington.

Of the many problems facing the US healthcare system, the shortage of behavioral health providers in outpatient settings is particularly profound. To address this issue, Boston׳s Brigham and Women׳s Hospital identified ways to incorporate behavioral health into primary care when it opened the South Huntington Primary Care clinic in August 2011. When the needs of its patients were more complex than anticipated, the clinic created assessment tools and refined care processes to identify, triage, and monitor patients with mental illness. Key insights from the South Huntington experience include. • Hiring for roles instead of training can decrease costs of implementation. • A process for reflection, assessment, and adaptation is a critical component of innovation. • Innovations must adapt to the specific needs of the local community. • Innovations are most effective when they reflect the capabilities of local providers.