Closing the Gap after Discharge from Rehab: An APP-led Transitional Care Clinic

Purpose: Transitional care clinics provide seamless care across care settings, including patients discharged from intensive care to rehabilitation facilities and then to home. Patients diagnosed with life-altering neurological diagnoses face challenges that can be compounded if the patient is discharged from rehabilitation without immediate neurological follow up
Description: Using quality improvement PDSA framework, we explored the feasibility of expanding upon an existing transitional care clinic that prioritized patients with hemorrhagic stroke who were discharged from hospital to home. The advanced practice provider (APP)-run transitional care clinic was adapted to facilitate the inclusion of patients who were discharged from hospital to rehabilitation prior to home
Outcome: Through the development of novel communication channels and integration of technological adjustments within the EHR, interprofessional teammates were able to share patient information across unique facilities. This enabled providers to discharge from hospital to rehabilitation to home while ensuring an opportunity for close transitional care clinical follow up
Conclusion: Transitional care clinics can be adjusted to broaden the scope of patients treated with the inclusion of appropriate professionals. Working with an interprofessional team enriches the resources available for our patients and contributes to immediate follow up care.