This paper presents early results from the implementation of a PDC for transitional care post-hospital or ED discharge. Our quantitative analysis showed a diverse patient population, predominantly comprised of Black, single, commercially-insured patients, utilized the PDC in its first year. Referrals to the PDC increased from 760 referrals (127 per month) in the first six months to 1408 referrals (235 per month) in the last six months, reflecting increased awareness of this transition clinic and partly resulting from collaboration with CTCC, highlighting its growing role in transitional care from hospital to community settings.
Marital status was association with appointment adherence; divorced, separated, or widowed individuals had higher cancellation and no-show rates, while single patients were more likely to not show up, possibly reflecting varying levels of social support affecting healthcare access and adherence.23,24 Patients with commercial insurance or Medicare attended appointments more consistently than those with Medicaid or no insurance, highlighting the healthcare accessibility and affordability issues, perhaps as a proxy for socioeconomic status.25,26 Addressing these barriers, e.g., reducing insurance complexities and out-of-pocket costs, and providing community health workers or patient navigators to those lacking endogenous social support, could improve appointment adherence. Racial disparities in appointment adherence were also found.
Similar to findings a large health system in Chicago, we observed a high no-show rate among PDC-referred patients.8 The persistent low attendance despite increased appointments has strained the clinic with patient engagement barriers. Both our quantitative and qualitative analyses suggest the high no-show rate issue is multifactorial, possibly rooted in socioeconomic barriers and a potential gap in patients’ understanding of the importance of post-discharge care. This gap, combined with limited awareness of the PDC's role, creates a confluence of factors affecting adherence as found in other post-discharge care studies.27,28 This underscores an opportunity to track an objective indicator readily measured at the point-of-care, to enhance the recognition of the perceived role and value of the PDC among health system leaders.
Behavioral differences associated with comorbidities were notable. Patients with hypertension showed greater adherence to follow-up care, likely due to increased health awareness or perceived healthcare need. In contrast, patients with mental health conditions like anxiety and depression had higher no-show rates, indicating barriers like stigma and motivational and organizational challenges for attending appointments.29 This calls for personalized approaches to improve attendance among persons with mental health conditions.30,31
The PDC’s integration within a large academic medical center is an important step towards improving resource access and bridging care gaps. Staff narratives underscored the need for dedicated social workers and specialists to address complex needs, particularly those related to social determinants of health. Initiatives could include targeted education campaigns, integrated care pathways, a tracking system for identifying no-show reasons, and community partnerships, to broaden the PDC's reach.
The PDC’s broader strategy needs to emphasize the leadership’s role in navigating its operational challenges and meeting the clinic’s goal of managing approximately 6,000 patients’ post-discharge care in the next two years. The initial attention of the clinical and administrative leadership was largely operational with far less systematic attention on marketing the PDC within the medical center. Engaging stakeholders is vital for raising PDC awareness and achieving patient volume and revenue goals. This engagement can address the “liability of newness”, transforming initial challenges into learning experiences, enhancing the PDC’s likelihood of success and contributing to the medical center’s culture and reputation.
This study has limitations. First, its findings, based on one institution, may not be broadly generalizable. Future research could consider comparing different PDCs, despite challenges due to the relative novelty of PDCs and their unique implementations across different healthcare systems. Second, our evaluation focused on scheduling/process measures, not clinical outcomes such as readmission rates or ED visits. Future research is planned to assess the PDC’s impact on patient care and system efficiency, crucial for scaling up this care model and guiding decisions for health system leaders in optimizing the portfolio of ambulatory care delivery options.
Similar clinics are being established in other health systems.2,8,32 The collective evidence seems to suggest their potential in post-discharge patient engagement. Our findings offer valuable insights for healthcare institutions contemplating PDC development, contributing to the growing body of knowledge on transitional care models and the iterative process of healthcare innovation. Promising early returns are balanced with challenges and opportunities for enhancement that will inform the evolution of the PDC at UAB and could help guide health systems in implementing such clinics.