At Charleston Internal Medicine we know that high-quality care also means seamless care. This is particularly important when it comes to patients being admitted or discharged from a hospital. Transitions of care can be a vulnerable time for patients, as they face an array of challenges.

For instance, when a patient is discharged from the hospital, he or she may need to understand and follow new instructions, take new medications, use new health tools or equipment, or need to schedule follow up care. And, we must ensure that all their other providers are updated on these changes. If not managed correctly, transitions of care can lead to hospital readmissions, health complications, or a decreased chance of long term improvement.

That’s why our practice has made closing the gaps created in transitions of care a priority. Just over two years ago, Charleston Internal Medicine brought on our own Hospitalist to care for all of our hospitalized patients. With a Hospitalist on staff, our patients have a physician from the primary care practice they trust on hand and caring for them during hospitalizations – which can be trying and difficult times. And, our practice has a direct line of communication and insight into our patients’ health and care. Our Hospitalist lets the practice know what she needs and sees in the inpatient setting, while we keep her informed on our patients in the outpatient setting.

Right away, we saw the impact of our Hospitalist program. Most notably the open communication through our Electronic Health Record allows full access to patients’ record and the ability to connect with a patients’ Primary Provider at any time. The outcomes have been significant: Charleston Internal Medicine patients’ average length of stay in the hospital is almost two days less than other patients at the local hospital.

Even so, we believed more could be done. So we added a Nurse Practitioner to work alongside the Hospitalist and manage patient communications. She communicates with the patient, family, and caregivers as to the changes in care and what is needed at and after discharge. The Nurse Practitioner also personally calls each patient within 48 hours of discharge to ensure the patient is managing the transition properly.

The follow up calls have had a clear impact. In talking with the patient after they’ve been discharged, our Nurse Practitioner invariably, finds a missed care gap, a change that needs to occur, or another issue to be corrected or communicated to the doctor. For example, twice in recent months, she has called patients after they’ve been discharged from the hospital to discover that their oxygen tanks were not delivered. She was able to follow up with the oxygen supplier to ensure immediate delivery to meet this critical need. This example illustrates that while a transitional care visit 4-5 days after discharge is standard, many issues can arise and cause serious health decline that lead to readmissions even before that visit, so reaching out to the patient within the first 2 days is vital.

Given our practice’s emphasis on transitional care management, joining the Aledade West Virginia ACO last year was an easy decision for us. We knew that Aledade shared our mission to focus on keeping our patients healthy, out of the hospital, and in their homes. We also knew Aledade would provide us with even more resources such as policy expertise, data and technology to continue this vital work. Participating in a value based program, like the ACO, gives us even more reason to focus on our patients’ full spectrum of health and wellness.

One of the major benefits of joining the ACO has been the ability to share innovative ideas that benefit our patients across other practices in our region. Our efforts around care transitions have worked so well that another Aledade ACO practice recently asked us to handle all care for their patients in the hospital as well. This assures our fellow ACO practice that their patients receive quality care, gives them direct communication with the hospital staff, and immediate communication upon discharge about pertinent issues that need to be addressed in outpatient setting.

The ACO has helped us to think even more creatively about key issues like transitions of care. Recently, we’ve also begun another initiative that helps improve transitions of care, reduce readmissions, and post-discharge health complications. We partnered with a local pharmaceutical school so that every Charleston Internal Medicine patient that is discharged sees the pharmacist and does a medication reconciliation. This ensures that any changes or new medications will not adversely affect the patient.

Patient satisfaction has skyrocketed since we have implemented these new systems. We have received many calls from patients, families, and caregivers expressing their gratitude for this added care that they have never received before. Knowing that we’re focusing on keeping our patients healthier while easing the minds of their caregivers has been extremely rewarding for our physicians and staff, and most importantly, better for our patients.