The first days after high risk patients leave the hospital are when they are most vulnerable to complications. UC San Diego Health launched a virtual transition of care clinic in 2021 to prevent complications and unnecessary readmissions.
“The real benefit for me relates to geography,” said Bob Lagomarsino, a patient from Sacramento who traveled to San Diego for a specialized procedure. He was able to follow up with a doctor virtually instead of making another trip.
His doctor, Sarah Horman, a hospitalist, was able to make sure his prescriptions were filled at his home pharmacy, addressed evolving symptoms and coordinated with his primary care doctor to ensure a smooth transition back to regular care.
“This is a video visit with one of our hospitalists and our goal is to see the patients within a week of discharge,” Horman, a professor at UC San Diego’s School of Medicine, said.
Horman and colleagues studied the impact virtual visits had on 2,314 high risk patients having to be readmitted to the hospital within 30 days compared to 23,129 who received the traditional standard of care. Their findings, published recently in the online edition of JMIR Medical Informatics, found the patients seen in the virtual clinic were readmitted 14.9% of the time compared to 20.1% for patients not seen in the clinic.
“Readmission rates for patients that we see are anywhere between 20% and 30% lower than patients than we don't see,” Horman said.
UC San Diego Health launched the program during the COVID-19 pandemic to overcome barriers to in-person visits like access, transportation and mobility.
“I've seen patients in homeless shelters, I've seen patients in drug rehab centers, sometimes they go home to a family member's house. Sometimes they don't even live in San Diego,” Horman said.
Unlike in-person follow-up clinics, which can see no-show rates as high as 50%, UC San Diego Health’s virtual clinic reports patients don’t show up less than 5% of the time.
“When you think about health equity and meeting our most vulnerable patients who are at highest risk after discharge, this really is the solution,” Horman said.
Readmissions are expensive for patients. Copays and deductibles add up with each visit.
And for hospitals, each readmission strains already limited staff and resources. In 2018, the national average cost of a readmission was more than $15,000 for the hospital.
“Readmissions cost our health system billions of dollars, and we need to free up beds for the next patients that are in need of our care,” Horman said.
The virtual transition of care clinic is staffed by hospitalists and interpreters are available. High risk patients are identified using a scoring system that factors in age, existing conditions, and prior hospital visits. The program currently serves patients at UC San Diego’s Hillcrest and Jacobs Medical Centers, with plans to expand.
Horman said it’s a model that could be scaled nationally to improve health outcomes and lower costs.
