Document Type

Poster Presentation

Publication Date





Establishment of Interdisciplinary healthcare teams have shown to improve health outcomes and lower readmission rates in medically complex patients during hospitalization. Exploration of interventions has happened largely during the pre-discharge phase rather than post-discharge. To extend the team based approach, we implemented a pilot study of an interdisciplinary discharge clinic to determine what impact a biopsychosocial approach to care can have on hospital readmission rates. This work was conducted at a large family medicine residency-based practice, and facilitated by a physician, behavioral health clinicians, a clinical pharmacist, nurse care managers, and medical assistant. Patients were seen in the discharge clinic within 7 days of hospital discharge. In addition to patient demographics, data collected prior to visits included the calculation of a LACE score to identify risk of readmission, utilizing the BOOST (Better Outcomes for Older Adults Through Safe Transitions) risk assessment tool to identify high-risk medications. Additional data collected during the team visit included a CESD (Center for Epidemiologic Studies Depression Scale) score and MOCA (Montreal Cognitive Assessment) score to determine any psychosocial barriers to optimizing patient care; these standardized measures were conducted as part of a larger clinical interview. The total number of medications pre- and post-visit were collected along with the number of medication related problems identified following a comprehensive medication review. The primary outcome is the number of patients readmitted in 30 days. Secondary outcomes include average length of visits, total number of medications pre and post visit, number of medication related problems identified, existence of social support systems, and degree of patient satisfaction with the team visit. Future considerations include developing a sustainable, reproducible model for interdisciplinary discharge care that includes a component of inter-professional education. "


Presented at: Society of Teachers of Family Medicine: Conference on Practice Improvement, Dallas TX, Dec. 2015.

Additional Files