Post-hospitalization discharge clinic: Who, What, When & Why?

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Poster Presentation

Publication Date



We attempted to prevent hospital readmissions by creating a new, interdisciplinary discharge clinic at our urban, residency-based practice. Within a week of discharge, patients were scheduled by care management to meet with a team of clinicians, including a physician, psychologist, pharmacist, and nurse care manager within the same visit. During the visit, we discussed the hospitalization primarily from the patient’s point of view, including patient perceptions of care, readiness for discharge, and issues surrounding medication reconciliation in an attempt to come to a shared understanding of readmission risk. Patients were also screened for mental health disease that could impact care, including depression and cognitive disorders. The team worked collaboratively with each patient to enhance patient understanding of the hospitalization, including safety with medications, gaps in care, potential reasons for readmission, and next steps for the patient. We found that patients overwhelmingly enjoyed the visits if they could adapt to a team-based approach, and we were able to identify actionable items for each patient to advance their care in the outpatient setting.
In this lecture we will present the specific content discussed in the visits, the rationale for this content in the post-discharge visit, and additional logistical workflows we created. Then we will present some of our preliminary findings from this work including the role of nonphysician leadership in the interdisciplinary team, potential for interprofessional education in the clinic, and where we hope to go next in doing this type of work in the field of hospital to medical home transition.

Upon completion of this session, participants should be able to:

  1. Start their own interdisciplinary discharge clinic to address preventable hospital readmissions
  2. Value and maximize the role of non-physician leadership in the interdisciplinary team
  3. Integrate interprofessional education into the discharge clinic by utilizing medical residents, pharmacy students, and behavioral health trainees into the team-based setting


Presented at the Society of Teachers of Family Medicine: Conference on Practice Improvement in Dallas Texas, December 4, 2015.

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