Increasing Patient Engagement in Primary Care following Transitional Care

Abstract

Overutilization of emergent care for primary health needs in the United States leads to poor utilization of resources, avoidable hospital readmissions, and costs an estimated 17 billion dollars annually. Issues impacting transition of care can cause incomplete follow-up and continued patient reliance on the emergency department (ED) for healthcare. Ensuring timely follow-up and engagement in primary care for patients discharged from acute care are major goals to reduce this economic burden and ensure effective care coordination. Transitional care provided by an after-care clinic (ACC) offers solutions to increase patient follow-up and coordinate entry, or engagement, in primary care. An ACC provided by a regional, urban health system has reduced overutilization and readmissions; however, engagement into primary care following acute care remains a challenge for the low income and uninsured population serviced.

This Doctor of Nursing practice (DNP) project implemented evidence-based practice (EBP) interventions of intra-appointment social determinants of health (SDOH) screening and post-appointment nurse-directed reminder phone calls to increase patient engagement in primary care following a transitional care appointment. Engagement was defined as completion of one primary care appointment within three months after the patient’s initial ACC visit. With the coronavirus (COVID-19) pandemic, continuity of care was provided with the addition of telemedicine; and although ACC staff hours were reduced and roles shifted, adding EBP to the bundled-care, interdisciplinary team approach for patients under the age of 40, who were uninsured or Medicaid insured, was cost effective and increased engagement in primary care.