Does the Hospital Medical Home Increase Primary Care Follow-Up among Pediatric Medical Patients?

Background: The New England Journal of Medicine (2009) found that over 50% of Medicare beneficiaries who were re-admitted to the hospital within 30 days did not have a follow up visit in the ambulatory care setting upon hospital discharge. O’Reilly (2011) stated that Piedmont Hospital in Atlanta reduced their hospital re-admission rate from 13.05% to 3.97% after implementing measures to improve medication reconciliation and identify high risk patients who are increased risk for hospital re-admission. Therefore, research suggests that primary care follow up visits may reduce hospital re-admissions. New York Methodist Hospital received funding from the New York State Department of Health to create a Hospital Medical Home in April 2013. The Hospital Medical Home sought to increase compliance with primary care hospital follow up visits within 14 days of hospital discharge and improve medication reconciliation upon hospital discharge among Medicaid pediatric medical patients. Another goal involved increasing collaboration with the inpatient and outpatient setting to identify high risk patients who were at high risk for hospital re-admissions in order to reduce hospital re-admissions and improve patient satisfaction. 

Methods: A nurse practitioner/care coordinator began working with the attending physicians and resident physicians at NYMH to increase primary care follow up among pediatric clinic patients. The nurse practitioner was notified of all upcoming discharges from the pediatric floor and pediatric intensive care unit and began meeting with patients and families to educate them on the importance of hospital follow up visits. In addition, the nurse practitioner called all pediatric and PICU discharges within 48 hours to remind them to attend a hospital follow up visit within 14 days of discharge. The nurse practitioner often saw these patients for their primary care follow up visits at the pediatric outpatient clinic, especially high risk patients. An electronic medical record was used to assess whether or not the implementation of the Hospital Medical Home improved patients’ compliance with primary care follow up visits within 14 days of discharge by comparing hospital admissions between Jan 2012 through June 2012 to hospitalizations between Jan 2014 through June 2014.

Results:  0 out of 75 pediatric patients who were admitted to the pediatric floor or pediatric intensive care unit between Jan 2012- June 2012 returned to the outpatient pediatric clinic for a primary care hospital follow up visit within 14 days of hospital discharge. However, 45 out of 65 (69%) pediatric patients who were admitted to the pediatric floor or pediatric intensive care unit between Jan 2014-June 2014 returned to the outpatient clinic for their primary care hospital follow up visit within 14 days of hospital discharge.

Conclusion: The Hospital Medical Home project improved patient outcomes by increasing patient’s compliance with a primary care follow up visit within 14 days of hospital discharge. The primary care follow up visit sought to coordinate care between the inpatient and outpatient setting and identify patients who are at high risk for re-admission. Further research needs to be done to reduce the number of hospital re-admissions that occur among all pediatric medical patients, especially among patients with chronic conditions such as sickle cell anemia and seizure disorder.