Seth Nikhil, Martinez George, Chapman Andrew, Child Nathan, Sikka Anika, Ghauri Arshad
Central Texas Veterans Affairs Hospital, Temple.
Texas A&M School of Medicine, Bryan.
Fed Pract. 2024 Jun;41(6):188-191. doi: 10.12788/fp.0476. Epub 2024 Jun 15.
The Olin E. Teague Veterans' Center (OETVC) is a teaching hospital with a medical ward consisting of 189 beds, 3 teaching teams with 1 resident and 2 to 3 interns, and 3 nonteaching teams. Due to the complexity of hospitalization, there are concerns that patients may not follow up with primary care or fill their prescribed medication and may have postdischarge questions.
A program was created at OETVC to bridge the gap between inpatient and outpatient care. Internal medicine residents call all teaching team patients a week following discharge. They discuss medications, changes in symptoms, follow-up plans, and address all questions. The residents also assist with missed orders and make treatment regimen changes if necessary.
This new program has proven to be beneficial. Residents are developing a better understanding of illness scripts and are working on communication skills without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, present condition, and follow-up. Data show a decreased 30-day readmission rate at 6% in the transition of care group compared to 10% in all patients who participated in the program. This program will continue to address barriers to care and adapt to improve the success of care transitions.
奥林·E·蒂格退伍军人中心（OETVC）是一家教学医院，其内科病房有189张床位，3个教学团队，每个团队有1名住院医师和2至3名实习生，还有3个非教学团队。由于住院情况复杂，有人担心患者可能不会跟进初级护理或服用处方药物，并且可能有出院后问题。
OETVC创建了一个项目以弥合住院治疗和门诊护理之间的差距。内科住院医师在患者出院一周后给所有教学团队的患者打电话。他们讨论药物、症状变化、后续计划，并解答所有问题。住院医师还协助处理遗漏的医嘱，并在必要时更改治疗方案。
这个新项目已证明是有益的。住院医师对疾病情况有了更好的理解，并且在没有时间限制的情况下提高沟通技巧。患者现在出院后能联系到医生，以讨论他们对住院治疗、当前状况和后续跟进的任何担忧。数据显示，护理过渡组的30天再入院率降至6%，而参与该项目的所有患者的再入院率为10%。该项目将继续解决护理障碍，并进行调整以提高护理过渡的成功率。
