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Implementation of a transition of care coordinator at a military treatment facility.

Safety, quality, and the cost of healthcare are currently at the forefront of healthcare discussions in the United States. One of the most vulnerable periods for a hospitalized patient occurs during transfer of that patient's care among providers or between healthcare settings. This risk is particularly significant for ill or elderly patients, since these transitions of care are prone to confusion, miscommunication, and medical errors. (1,2)

Within hospital systems, discharge planning services aim to ease the patient transition from the hospital. Many studies suggest that these services decrease cost and utilization rates. A 2013 Cochrane review evaluated the value of hospital discharge planning and determined that individualized hospital discharge plans lead to reductions in hospital length of stay and readmission rates. (3) Additional evidence in the Cochrane review was inconsistent regarding the impact of discharge planning on cost, mortality, or other health outcomes.

When compared to the availability of hospital-based discharge planning services, fewer systems exist to assist patients after discharge from the hospital. Often, patients experience problems which arise after their hospital discharge, but prior to a follow-up appointment. During this time, hospital discharge planners are not always available, and the patient's primary care medical home may be unaware of the hospitalization. Specific problems that may arise during the transition of care from the hospital include inaccurately reconciled medication lists, inadequate access to appropriate social support or transportation to appointments, poorly coordinated postdischarge home medical services, or lack of access to a physician for follow-up outpatient care. Each of these issues can contribute to medical errors, patient morbidity, and rehospitalization rates. (4,5) As these problems have become more apparent, they have become increasingly studied in an attempt to decrease costs while improving patient safety and the quality of care delivered during the transition periods.

One of the strongest bodies of evidence supporting a deliberate approach to facilitating care transitions is described in Boston University's Project RED (Re-Engineered Discharge) research group (https://www. Project RED researchers executed and evaluated strategies for successful patient transition from the inpatient to the outpatient care settings. Through the development and implementation of their first discharge protocol, Project RED significantly reduced both hospital readmissions and postdischarge visits to the ED. (6) As an additional part of their project, they published a tool kit for other health teams to employ when discharging patients. (7) Other studies demonstrated similar evidence with regard to the effect of discharge planning protocols on ED utilization and hospital readmission rates. (8-11)

Studies such as these have led to campaigns throughout the United States designed to improve the quality of patient care delivered during this transition period. One of the largest such campaigns is the 2010 Partnership for Patients Campaign led by the Department of Health and Human Services. As part of this campaign, over 3,700 hospitals have collaborated in order to make hospitals safer, less costly, and more reliable. One of the 2 cornerstone goals of the Partnership for Patients campaign is to reduce hospital readmissions by 20%. (12) The Department of Defense and the Military Healthcare System (MHS) joined other federal agencies to support the Partnership for Patients campaign. (13) As part of its campaign, the MHS recommended adoption of the Project RED toolkit within its healthcare facilities.

Based on this MHS recommendation and other local mandates to improve the quality of healthcare within our institution, the leadership of the Womack Army Medical Center established a Project RED team to facilitate transitions of care throughout its health system. As part of this effort, the Family Medicine residency clinic implemented the use of a licensed clinical social worker to serve as the transitions of care coordinator (TOCC) for patients enrolled in the residency clinic and cared for by the Family Medicine inpatient team. The TOCC's primary role was to enable effective and safe transitions of care from the inpatient ward to the follow-up outpatient appointment. With the implementation of the TOCC, our objectives were to increase the number of patients that had follow-up appointments with their primary care manager (PCM) shortly after hospital discharge, identify and assist with patient problems posthospitalization, decrease the frequency of emergency department (ED) visits posthospitalization, decrease hospital readmissions to the Family Medicine inpatient team, and improve the overall quality of care for our high acuity patients. Overall, we aimed to study the relative quality metrics associated with implementation of a transitions of care coordinator within an academic clinic in the MHS.


This study was conducted as a local quality improvement initiative. Within our Family Medicine residency clinic at a large Army military treatment facility, we implemented a TOCC to facilitate a smoother transition to outpatient healthcare for patients recently discharged from the hospital. We chose a licensed clinical social worker to assume this role.

The initial step in our transition of care protocol was for the TOCC to contact all patients discharged from the Family Medicine inpatient team within 48 hours of discharge. The TOCC used a structured interview script based on Project RED guidelines which reviewed the patient's diagnosis, discharge medications, follow-up appointments, consultations, and overall plan of care. The TOCC was also responsible for confirming that each of the patients had a follow-up visit in our clinic (preferably with the primary care manager), answering patients' questions about their hospitalization, ensuring patients received any indicated postdischarge services, bringing medication reconciliation questions to the attention of the inpatient team and the PCM, and addressing any additional patient concerns. The TOCC conducted these encounters telephonically and documented the results within the electronic medical record.

All adult admissions to the Family Medicine inpatient team from February 2013 through March 2014 were evaluated monthly for primary outcomes data. Chart reviews were conducted with the following primary outcome variables recorded:

1. Number of patients contacted by the TOCC within 48 business hours.

2. Number of patients who completed a follow-up visit within 7 days of discharge in our practice.

3. Number of patients who completed a follow-up visit within 7 days of discharge with their PCM.

4. Number of patients who completed a follow-up visit within 14 days of discharge in our practice.

5. Number of patients who completed a follow-up visit within 14 days of discharge with their PCM.

6. Number of ED visits within 30 days of admission.

7. Number of readmissions to our facility within 30 days of discharge.

A run chart was constructed from this data to identify any emerging trends. At 6 months following the TOCC implementation, the data was analyzed by run charts as well as via SPSS Statistics 20.0 (IBM Corp, Armonk, New York) analysis.


Table 1 shows the demographic characteristics of the patient groups admitted to the Family Medicine inpatient adult medicine service during the preimplementation and the postimplementation periods. Outcome variables were assessed comparing the preimplementation and the postimplementation periods for the TOCC. During this analysis, we did not consider whether the TOCC actually contacted the patient during the postimplementation period, as this happened within 48 hours in only 40% of cases. Table 1 also compares outcome variables for these periods regardless of TOCC contact. As expected, the number of documented patient contacts by our primary care office in the postdischarge period increased significantly after implementation of the TOCC (3.1% vs 40.2%, P=.01). Additionally, the percentage of ED visits (11.9% vs 20.8%, P=.02) and hospital readmissions (5.6% vs 13.7%, P=.01) increased during the postimplementation period.

Figure 1 shows the run chart of primary outcome measures after we implemented the TOCC. Over the course of 6 months, the number of patients from our practice contacted within 48 business hours after hospital discharge rose from approximately 20% to 70%. During this time period, the percentage of patients completing a follow-up appointment within 14 days of discharge also increased. This increase also included the number of patients that were able to see their PCM. The percentage of ED visits as well as the percentage of patients readmitted within 30 days appeared to have a declining trend after our implementation. No trends were identified for patients following-up within 7 days of discharge.

The postimplementation data was analyzed for correlations using Pearson product moment correlation. The Pearson coefficients between variables is presented in Table 2. In the post implementation period, receiving a phone call within 48 hours postdischarge from our TOCC correlated inversely with 30-day readmissions, as well as ED visits following hospital discharge (r= -0.68, P=.05 and r=0.062, P=.005, respectively). The 14-day PCM follow-up visit also correlated, though less strongly, with decreased ED visits and 30-day readmissions following discharge (r=-0.13, P=.017 and r= -0.31, P=.006, respectively).

The postimplementation period was also analyzed to determine if an actual contact within 48 hours by the TOCC or within 14 days by the PCM made differences in patient outcomes among this group. Tables 3 and 4 show this data. Contact by the TOCC within 48 hours did not significantly change the frequency of posthospitalization ED utilization or hospital readmission rates. Patient follow-up within 14 days of hospitalization with the PCM led to an increase in ED visits (14.9% vs 27.3%, P=.02), but did not lead to significant differences in readmission rates.

Finally, data from February and March of 2013 was compared to data from February and March of 2014 to identify possible seasonal variation. In 2014, there was a slight reduction in ED visits following implementation of the TOCC (Figures 2 and 3). Between 2013 and 2014, there was an absolute rate reduction of 3.2% and 2.4% for ED visits in February and March, respectively. Between 2013 and 2014, there was an absolute rate increase of 3.8% in February 2014 and reduction of 4.9% in March 2014 for 30 day hospital readmissions, respectively.


As part of our study design, we theorized that the implementation of a TOCC would decrease health care utilization within our system, specifically with ED visits and hospital readmissions within 30 days. However, review of the overall preimplementation and postimplementation data suggests that our population's ED visits and readmissions actually increased after our TOCC initiative. Similarly, when considering the possible benefits of provider continuity in the postdischarge period, we theorized that higher rates of PCM visits would decrease utilization rates. This was not the case, however, as patients seeing their PCM within 14 days during our postimplementation period had significantly higher ED utilization and hospital readmission rates.

The cause of these seemingly paradoxical results is unclear. Patients typically have increased morbidity rates in the posthospitalization period. Increased contact by our outpatient practice may be simply identifying problems or complications at an earlier time period.

Although this may negatively affect utilization rates, it may be providing improved quality of care in regard to long-term patient outcomes. This was not evaluated in our study. Also, examining data from across our entire medical center would generate stronger statistical power to assess the increased utilization rates.

In our postimplementation period, higher rates of timely contact by the TOCC was inversely correlated with the ED and hospital utilization rates, as evaluated by a Pearson correlation. However, [chi square] analysis of these measures in the same period did not show significantly decreased rates of utilization for those same patients. These trends still suggest promise of utilization and cost savings benefit to our hospital as the program continues to mature.

The implementation of a TOCC led to a significant portion of our practice patients being contacted within 48 hours of a hospitalization. The goal of 100% patients contacted with 48 hours of discharge was not met due to transfers to other facilities, deaths, and a myriad of administrative challenges.

Timely patient contact was hampered by incorrect phone numbers, patients who did not return phone calls, and the lack of an alternate TOCC when the primary TOCC was on vacation or ill. Despite these limitations, most patients not contacted within the first 48 hours following discharge were contacted by our practice within a week.

The use of a licensed clinical social worker as our TOCC is unique since most facilities use nurses for this function. The potential drawbacks of using a social worker in the role include unfamiliarity with the medications reviewed as part of the 48-hour telephone encounter. To mitigate this issue, when our TOCC identified a medicine reconciliation issue, he relayed the concern to both the discharging inpatient team as well as to the PCM. The advantages of using a social worker as a TOCC include an understanding of how to navigate a complex medical system, experience in the coordination of outpatient specialty referrals and appointments, and an appreciation of the influence of family dynamics on a patient. Additional benefits of employing a social worker in this role include professional training and experience with counseling patients and clear communication and emotional support.

There are several limitations to our study. We did not consider variables other than those described above. During the period that the TOCC was established, additional changes within our health system occurred which may have influenced our results. The Family Medicine inpatient team standardized the written discharge summary and instructions given to all patients. Additionally, the ED transitioned from a paper health record to an electronic medical record. Each of these changes may have independently affected our study's outcomes or the ability to capture data accurately. The standardized discharge summary was part of an overall quality improvement measure for the Family Medicine inpatient team and was designed in accordance with Project RED and Medicare documentation requirements with their emphasis on improved readability. Additionally, we only studied patients within our military medical system. Our practice patients who were admitted to hospitals other than our facility were not included in the analysis.

Despite the unanticipated outcomes involving ED utilization and hospital readmission rates after our intervention, the strategies used by our team within this quality improvement initiative subjectively enhanced communication and coordination of care within our practice. These benefits included clear communication of the study's objectives, a standardized script for the TOCC, a standardized discharge summary format for the Family Medicine inpatient team, and the establishment of common, obtainable goals. We believe that the value we derived from these strategies can be replicated, and should be used throughout the MHS.


The implementation of a TOCC within an academic clinic at a large MTF has significantly increased our patient population's frequency of ED visits and hospital readmissions after discharge. However, trends during our postimplementation period suggest possible future benefit of a TOCC if assessed over a longer period of time. The broader medical literature still largely supports an overall cost, quality, and utilization benefit by improving transitions in care. Therefore, the MHS should investigate the utility of this effort on a larger scale.

LTC Dana Nguyen, MC, USA

CPT Blake Busey, MC, USA

LTC Mark Stackle, MC, USA

Tammy Donoway, DO

CPT Sarah Strickland, MC, USA

CPT Ashley Roselle, MC, USA

CPT Scott Hahn, MC, USA

CPT Nick Bennett, MC, USA


(1.) Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.

(2.) Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

(3.) Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev. [serial online]. 2013;1.

(4.) Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. "Did I Do as Best as the System Would Let Me?" Healthcare professional views on hospital to home care transitions. J Gen Intern Med. 2012;27(12):1649-1656.

(5.) Balaban RB, Weissman JS, Samuel PA, et al. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23:1228-1233.

(6.) Jack BW, Chetty VK, Anthony D, et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):179-197.

(7.) Jack B, Greenwald J, Forsythe S, et al. Developing the tools to administer a comprehensive hospital discharge program: the ReEngineered Discharge (RED) Program. In: Henriksen K, Battles JB, Keyes MA, et al, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools). Rockville, MD: Agency for Healthcare Research and Quality. 2008. Available at: NBK43688/. Accessed December 24, 2015.

(8.) Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch of Intern Med. 2006;166:1822-1828.

(9.) Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC Health Serv Res. 2014;14:346.

(10.) Cauwels JM, Jensen BJ, Winterton TL. Giving readmission numbers a BOOST. S D Med. 2013;66(12):505-509.

(11.) Constantino ME, Frey B, Hall B, Painter P. The influence of a postdischarge intervention on reducing hospital readmissions in a medicare population. Popul Health Manag. 2013;16(5):310-316.

(12.) Department of Health and Human Services. Partnership for Patients Campaign Website. Available at: Accessed January 10, 2015.

(13.) Military Health System. Implementation Guide for Readmissions. Washington, DC: US Dept of Defense; February 13, 2014. Available at: http:// uments/2014/02/13/Implementation-Guide-for-Re admissions. Accessed January 10, 2015.


LTC Nguyen is Clerkship Director, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

CPT Busey is a Staff Physician, Soldier Family Medical Clinic, Fort Bliss, Texas.

LTC Stackle is Deputy Commander for Clinical Services, BG Crawford Sams US Army Health Clinic, Camp Zama, Japan.

Dr Donoway and CPT Roselle are Staff Physicians, Department of Family Medicine, Womack Army Medical Center, Fort Bragg, North Carolina.

CPT Strickland is a Staff Physician, Reynolds Army Community Hospital, Fort Sill, Oklahoma.

CPT Hahn is a Staff Physician, Darnall Army Community Medical Center, Fort Hood, Texas.

CPT Bennett is a Staff Physician, Farrelly Health Clinic, Fort Riley, Kansas.

Table 1. Comparison of patient outcome variables for
preimplementation vs postimplementation of a TOCC.

                          Preimplementation   Postimplementation
  Patients (N)                   160                 256
  Men (%N)                   82 (51.2%)          125 (48.8%)
  Average Age (years)            57                   61
Outcome Results [n(%N)]
  48-hour Call                5 (3.1%)           103 (40.2%)
  7-day Appt                 77 (48.1%)          128 (50.0%)
  7-day PCM Appt             47 (29.4%)           84 (32.8%)
  14-day Appt                106 (66.3%)         171 (66.8%)
  14-day PCM Appt            68 (42.5%)          121 (47.3%)
  ED Visits                  19 (11.9%)           53 (20.8%)
  30-day Readmission          9 (5.6%)            35 (13.7%)

                          P value
  Patients (N)
  Men (%N)
  Average Age (years)
Outcome Results [n(%N)]
  48-hour Call              .01
  7-day Appt                .71
  7-day PCM Appt            .46
  14-day Appt               .91
  14-day PCM Appt           .34
  ED Visits                 .02
  30-day Readmission        .01

Table 2. Pearson Correlation Coefficients between
primary outcome variables post-TOCC implementation.

Pearson Correlation Coefficients

                                           r     P value

48-hour Call   14-day Follow-up          0.23     .016
               14-day PCM follow-up      0.63     .936
               ED visits per admission   -0.68    .050
               30-day Readmission        -0.62    .005
14-day PCM     48-hour Call              0.63     .936
  Follow-up    ED Visits per admission   -0.13    .017
               30-day Readmission        -0.32    .001

Table 3. Comparison of emergency department and
readmission outcomes between patients (N=256)
who were contacted by the TOCC vs those who were
not contacted.

48-hour Call          No n(%N)      Yes n(%N)    P value

Patients             153 (59.8%)   103 (40.2%)
ED Visits            30 (19.7%)    23 (22.3%)      .62
30-day Readmission   22 (14.5%)    13 (12.6%)      .67

Table 4. Comparison of emergency department and
readmission outcomes between patients (N = 256)
that completed a follow-up appointment within 14
days and those that specifically saw their PCM).

14-day Follow-Up         No            Yes         P
                        n(%N)         n(%N)      value

Patients             85 (33.2%)    171 (66.8%)
ED Visits            16 (19.0%)    37 (21.6%)     .63
30-day Readmission   13 (15.5%)    22 (12.9%)     .57

14-day PCM               No            Yes         P
Follow-Up               n(%N)         n(%N)      value

Patients             135 (52.7%)   121 (47.3%)
ED Visits            20 (14.9%)    33 (27.3%)     .02
30-day Readmission   18 (13.4%)    17 (14.0%)     .89

Figure 2. Comparison of outcome data between a
preimplementation month (February 2013) and a
postimplementation month (February 2014).

                          Feb 2014   Feb 2013

48-hour Call              0%         52.9%
ED Visits per Admission   15.0%      11.8%
30-day Readmission        5.0%       8.8%

Note: Table made from bar graph.

Figure 3. Comparison of outcome data between March 2013
(preimplementation) and March 2014 (postimplementation).

                          Mar 2014   Mar 2013

48-hour Call              3.3%       71.8%
ED Visits per Admission   20.0%      17.6%
30-day Readmission        10.0%      5.1%

Note: Table made from bar graph.
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Article Details
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Author:Nguyen, Dana; Busey, Blake; Stackle, Mark; Donoway, Tammy; Strickland, Sarah; Roselle, Ashley; Hahn,
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2016
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