<mods:mods xmlns:mods="http://www.loc.gov/mods/v3" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://www.loc.gov/mods/v3 http://www.loc.gov/standards/mods/v3/mods-3-7.xsd"><mods:titleInfo><mods:title>Process Engineering at Providence Community Health Center North Main: Transitions of Care Following Hospital Discharge</mods:title></mods:titleInfo><mods:abstract>Background: A Rhode Island state initiative states that hospitalized patients should see their primary care provider within seven days of discharge. Studies demonstrate that patients who make follow-up appointments during their hospital stay are 20% more likely to attend that visit than patients who make appointments after discharge. We aimed to improve transitions of care for hospitalized Providence Community Health Center (PCHC) North Main patients
Methods: We undertook an iterative PDSA cycle process to initiate and then refine our transitions of care protocols. We utilized the Rhode Island Quality Initiative database to monitor hospitalized PCHC patients. The patients’ admission diagnoses were classified as either medical or behavioral. Follow-up appointments were scheduled by the PCHC medical assistant. We started with a focus on homeless hospitalized patients.
Results: PDSA cycle 1, focused on homeless PCHC patients. Zero patients were hospitalized. Therefore PDSA cycle 2, was expanded to all PCHC hospitalized patients. 17 of 35 were successfully scheduled for follow-up appointments at PCHC. 15 patients (43%) were hospitalized for behavioral health diagnosis, prompting a need to coordinate with The Providence Center (TPC). In PDSA cycle 3, five of the six (83%) hospitalized patients were admitted for behavioral health diagnoses and were successfully referred to the TPC liaison to schedule a TPC appointment.
Conclusion: These cycles solidified a transition of care flowchart for discharged PCHC patients. Depending on their admission reason and status with TPC, the patient would either be contacted by the PCHC staff or referred to TPC to transition care.</mods:abstract><mods:name><mods:namePart>Reczek, Annika</mods:namePart><mods:role><mods:roleTerm authority="marcrelator" authorityURI="http://id.loc.gov/vocabulary/relators" valueURI="http://id.loc.gov/vocabulary/relators/aut">Author</mods:roleTerm></mods:role></mods:name><mods:originInfo><mods:dateCreated>2020</mods:dateCreated></mods:originInfo><mods:subject authority="local"><mods:topic>mental health</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>behavioral health</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>community health center</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>emergency medicine</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>Continuity of Care</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>Hospital</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>Emergency Room</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>PDSA Cycles</mods:topic></mods:subject><mods:subject authority="local"><mods:topic>Transitions of Care</mods:topic></mods:subject><mods:typeOfResource>still image</mods:typeOfResource><mods:genre>posters</mods:genre><mods:accessCondition type="rights statement" xlink:href="http://rightsstatements.org/vocab/InC/1.0/">In Copyright</mods:accessCondition>
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All rights reserved. Collection is open for research.
</mods:accessCondition><mods:identifier type="doi">10.26300/4zcm-aj32</mods:identifier></mods:mods>