Transition Clinic
Starting Monday, 3/26/18, ED physicians and ACP’s will have a new option to offer to select patients for outpatient follow-up after ED discharge.
The Transition Clinic is a medical office located on the campus at CMC Main (by the Scott Deck). Its staff provide post-discharge care for patients recently admitted to the hospital. Under Medical Director Dr. Stephanie Murphy, they help to ensure thorough and timely outpatient care during the high-risk weeks following admission, after which the patient resumes seeing his or her primary care doctor.
ED patients who have been recently (within 30 days) admitted to an Atrium Hospital will be eligible for follow-up at this clinic as well.
The aim of this project is to provide a robust follow-up solution for patients who may be able to avoid a hospital admission with the assurance of having short term outpatient follow-up. Please consider this option in your thought process when discharging patients.
Referrals will be exclusively for patients who present with all of the following criteria:
Please refer to the attached documents for information on the simple process for referring patients to Transitions. Please provide the attached “Discharge Instructions” to every patient you refer (this will be added to the Depart Workflow in the coming weeks).
We hope to reduce hospital re-admission for patients who would derive greater benefit from a robust outpatient care experience.
FAQs
The Transition Clinic is a medical office located on the campus at CMC Main (by the Scott Deck). Its staff provide post-discharge care for patients recently admitted to the hospital. Under Medical Director Dr. Stephanie Murphy, they help to ensure thorough and timely outpatient care during the high-risk weeks following admission, after which the patient resumes seeing his or her primary care doctor.
ED patients who have been recently (within 30 days) admitted to an Atrium Hospital will be eligible for follow-up at this clinic as well.
The aim of this project is to provide a robust follow-up solution for patients who may be able to avoid a hospital admission with the assurance of having short term outpatient follow-up. Please consider this option in your thought process when discharging patients.
Referrals will be exclusively for patients who present with all of the following criteria:
- Adults ≥ 18 years old.
- Hospital admission to any CHS facility within the past 30 days (identified via the Bounceback Icon in LaunchPoint).
- If admitted again, the patient would be a CHG admission (i.e., recent trauma or surgical patients who present with acute medical concerns are eligible if their current issue is primarily medical).
- Complaints / health needs are NOT primarily psychiatric or pain related.
- Clinically appropriate for discharge.
Please refer to the attached documents for information on the simple process for referring patients to Transitions. Please provide the attached “Discharge Instructions” to every patient you refer (this will be added to the Depart Workflow in the coming weeks).
We hope to reduce hospital re-admission for patients who would derive greater benefit from a robust outpatient care experience.
FAQs
- Myers Park patients (i.e., patients who routinely follow up at the Myers Park IM clinic) – for now, please do not refer these patients to Transition Services for followup. This is an ongoing discussion and may change.
- Direct Messaging – I wanted to emphasize that it is entirely OK to directly message the Transition Clinic to refer the patient for followup, rather than asking for Josie’s assistance (i.e., your choice). I would especially encourage this when Josie is not available (after hours, weekends, e.g.) but you can do so even if she is in house. Please share any feedback with me on this, as we may move towards doing this as the primary means of referral if it works well for everyone.
- For now, if you do message the clinic directly, please also fill out the fast track form and check the box for Cerner Message Sent
- Send the referral message to “CMC Transition Clinic, Referrals”
- Include the patient’s info (Name, MRN or link the chart directly) and best contact phone number, and mention that this is an ED Referral
