Disclosures: Keith Polston, MD: No financial relationships or conflicts of interest

Objective: To implement an algorithm to delegate responsibility for scheduling primary care physician (PCP) follow-up appointments after inpatient rehabilitation facility (IRF) and to analyze effectiveness of this system in reducing readmissions.

Design: Prospective cohort studySetting : The University of Kansas Medical Center Acute Inpatient Rehabilitation between January 1, 2021 and January 31, 2021Participants : 61 patients discharged during the above period

Interventions: An algorithm was developed to determine who is responsible for scheduling follow-up appointment (e.g., physician, family member, patient, etc.). When feasible, this task was assigned to the patient to complete as a therapeutic activity. Two “smart phrases” were utilized within the electronic medical record (EMR) – one to identify PCP and assign responsibility for scheduling, and one for confirming scheduling on the patient’s after-visit summary (AVS).

Main Outcome Measures: Outcome measures included overall compliance with the use of AVS smart phrase and 30-day readmission rates for patients discharged during this period vs. rates for patients discharged during the previous calendar year.

Results: Compliance with PCP follow-up process and use of the smart phrase was100%. 61 patients were discharged during the above period. Of those 61 patients, 7 (11.5%) had an unplanned readmission within 30 days of discharge. This compared to 14% overall 30-day unplanned readmission rate for 2020.Conclusions: Rapid PCP follow-up after IRF has been found to result in lower readmission rates. Barriers remain to securing these appointments. An algorithm to delegate scheduling of PCP follow-up appointments is a simple solution to maximize opportunities to secure an appointment before discharge from IRF. Further analysis of preliminary data, implementation over longer periods of time, and implementation in larger patient groups will be our next steps in determining whether this intervention results in significantly decreased readmission rates. Notably, the COVID-19 pandemic presents an ongoing barrier both to securing PCP appointments and comparing data to that of previous years.

Level of Evidence: Level II

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/reducing-readmissions-implementation-of-algorithm-to-assign-scheduling-of-primary-care-follow-up-appointments-after-acute-inpatient-rehabilitation/