Implementation of a Transition of Care Coordinator at a Military Treatment Facility

UNLABELLED: A patient's transition from the inpatient to the outpatient setting is complex and prone to medical errors. This subsequently increases patient morbidity and cost to the healthcare system.

METHODS: Our quality improvement initiative used a licensed clinical social worker from within a Family Medicine residency clinic to serve as a Transitions of Care Coordinator (TOCC) with the goal of decreasing patient morbidity and system cost.

RESULTS: The number of documented patient contacts by our primary care office in the postdischarge period increased significantly after implementation of the TOCC (3.1% vs 40.2%, P=.01). Pearson correlation during our postimplementation period suggested an inverse relationship between contact by a TOCC and emergency department (ED) and hospital utilization rates (r=-0.68, P=.05 and r=0.062, P=.005, respectively). However, the percentage of ED visits (11.9% vs 20.8%, P=.02) and hospital readmissions (5.6% vs 13.7%, P=.01) significantly increased overall between the pre-and postimplementation periods.

CONCLUSIONS: The implementation of a TOCC within a military Family Medicine residency clinic significantly increased the frequency of ED visits and readmissions to the inpatient service for patients discharged from the Family Medicine inpatient service.