The collaborative pilot program included an inpatient service and partner primary care clinics in the San Francisco Health Network. Per the program, the inpatient team sent care transitions emails at patient admission and discharge to inpatient team members and primary care team members. Each primary care clinic selected its own recipient list, which included the primary care provider plus other designated staff. Researchers assessed patient outcomes and provider work experience over two years.
The program resulted in sustained improvements in care coordination. Researchers found a 14 percent increase in follow-up appointment attendance within seven days of discharge among patients involved in the pilot program. The increased attendance for follow-up appointments reduced 30-day all-cause readmissions by 58 percent during the study period.
Additionally, of outpatient providers involved in the pilot who were surveyed, 93 percent recommended that the program be adopted system wide. A majority of providers reported the intervention improved the ease and efficiency of care transitions.
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