Project Information

Review of Transitions of Care Clinic - Internal Medicine Medical Plaza

Project Description: Last year Internal Medicine at Medical Plaza (IMMP) developed an interprofessional transitions of care (TCM) clinic. Currently the clinic operates every Wednesday afternoon. Our primary goal is to reduce 30 day hospital readmission and ed utilization. Currently, after discharge from UF Health all patients are contacted to make sure they are doing well since discharge, reconcile medications, and arrange clinic follow up. Our primary goal are for patients to follow up with their primary care physician within 2 weeks. If this isn't possible the TCM clinic provides additional access. Prior to the clinic session we meet as an interdisciplinary group from 1-1:30 and discuss the pts we are seeing that day. The team consists of pharmacy, social work, home health, nursing, medical student, resident, and attending. We focus on the issues that might keep patient from being readmitted. Patients are then seen by the physician along with other team members felt to be necessary at that time. Our team would like to perform a chart review to determine the effectiveness of our TCM clinic on reducing hospital readmission. Our plan is to review patients seen by our TCM clinic vs a cohort of IMMP patients discharged from UF Health who were not seen in the TCM clinic. We will collect data in UF CTSI REDCAP. Data to be collected include (a copy of this REDCAP tool can be sent) : 1. Pt demographics 2. Pt chronic health conditions (DM, HTN, CAD, etc) 3. Characterization of Hospital Admission (ie. Icu vs IMC, LOS, etc) 4. Follow-up (days until follow up in clinic, was appointment schedule) 5. Medication issues (how many medications, high risk meds, medication changes) 6. Did patient attend transition clinic? 7. Days until readmission 8. Days until ED visit

QPI: Ryan, Nall, (



UF Health Big Aims: Increase Value None

MeSH Keywords: Physicians, Primary Care, Transitions of Care, Interprofessional, Readmissions, Team