Major Innovations in Transitions of Care at Health Services

Major Innovations in Transitions of Care at Health Services

By: Anshu Abhat, MD MPH, Drumil Bhatt MD, Belinda Waltman, MD, Debra Duran RN, Fiorella Arcidiacono RN, Carmen Mendez, MD, and Griselda Gutierrez, MD

Major Innovations in Transitions of Care at Health Services

Major Innovations in Transitions of Care at Health Services 800 450 Health Services Los Angeles County

Transitions of care (TOC) have really improved from Health Services hospitals to clinics in the last 2 years! For example at Harbor-UCLA Medical Center in 2019, 32% of Health Services patients were following up with their primary care provider within 14 days of hospital discharge. Now, 65% of Health Services patients follow up with their primary care provider within 14 days of hospital discharge!

Improvements in TOC have been a true collaborative team effort. In the past, arranging discharge follow-up was extremely labor intensive for the inpatient providers and there was no consistent workflow. Inpatient providers relied on phone scheduling to our 29+ Health Services clinics. Primary care providers were often sorting through ORCHID message requests for follow-up. The lack of consistent workflow was not only time consuming, but also resulted in inconsistent care for our patients.

In collaboration with Health Services Population Health, primary care medical directors, specialty care directors, hospital patient access centers (PACs), nursing directors and inpatient leads, a new TOC workflow was developed to increase the number of patients receiving timely post-discharge follow up within 14 days.

Providers can now click a “discharge appointment” order in ORCHID that goes directly to the hospital PAC queue. Hospital PACs can now schedule the requested appointment within any of our Health Services clinics within 2 hours.

Timeline:

November 2019

Initial test workflow was at El Monte Health Center Comprehensive Health Center and LA General Medical Center

March to June 2020

PC launched post-discharge cross scheduling process from hospitals to Primary Care Medical Homes (PMCHs) across Health Services

November 2020

Harbor-UCLA Medical Center launched ORCHID order for PC and SC

May 24, 2021

LA General Medical Center launched ORCHID order for PC and SC

June 14, 2021

Rancho Los Amigos National Rehabilitation Center launched ORCHID order for PC and SC

June 14, 2021

Olive View-UCLA Medical Center launched PC.  SC to be determined, but coming soon

PC = Primary Care

SC = Specialty Care

Since the new ORCHID order launched at Harbor-UCLA Medical Center in November 2020, the Harbor Patient Access Center has scheduled 6,400 post-discharge appointments! We saw how successful this change has been to improve TOC for our patients, and this standardized workflow is now live at all Health Services hospitals. By expanding to all Health Services hospitals, we expect to exceed the current success rate of 65%. Improving TOC aligns with our Health Services vision to be nationally recognized as a model integrated health system in patient care.