UMC offering transitional care to discharged hospital patients

When some patients are discharged from the hospital after being treated for an acute condition, they need help transitioning back into their everyday life—and making sure they are not readmitted.

University Medical Center, which is operated by The University of Alabama’s College of Community Health Sciences, is now helping these types of patients on a weekly basis with its new Transitional Care Clinic located in the Department of Family Medicine. The clinic is held every Thursday morning and is currently seeing about five to eight patients every week.

The clinic was developed through an interprofessional collaboration among the Family Medicine, Pharmacy and Social Work departments along with a partnership with DCH Regional Medical Center. The efforts have been spearheaded by Dr. Tamer Elsayed, assistant professor in the Department of Family Medicine.

Elsayed, who is a recent graduate of the College’s Family Medicine Residency, says the aim of the clinic is to provide services to patients who face medical or social issues that require special attention in the transition. He says the clinic addresses barriers patients face when obtaining health care, such as transportation or the cost of medication.

“Our target is to provide the patients with the means to maintain health and avoid complications of chronic health problems,” he says.

From left, Amy Yarbrough, LPN, Dr. Tamer Elsayed, assistant professor in Family Medicine, and Kim McMillian, LPN

From left, Amy Yarbrough, LPN, Dr. Tamer Elsayed, assistant professor in Family Medicine, and Kim McMillian, LPN

Kim McMillian, LPN, a nurse in family medicine and a primary care patient advocate for University Medical Center, works with DCH to identify UMC patients who have been treated at DCH for chronic conditions, such as chronic obstructive pulmonary disease, congestive heart failure, diabetes. The patients are contacted within two days, McMillian says.

“We’ll contact them to make an appointment, and make sure they have what they need at home,” she says. “We try to reconcile their medications and make sure they can get to their appointment.” The biggest issues facing patients are coping with their diagnosis as well as transportation, McMillian says.

An appointment must take place within seven to 14 days, and the patient will meet with Elsayed as well as a pharmacist or social worker. Also working the clinic are: Dana Carroll, PharmD, assistant professor in Family Medicine and the Pharmacy departments; Robert McKinney, LCSW, and Cynthia Tyler, MSW, both social workers for University Medical Center; and Amy Yarbrough, LPN, a nurse in Family Medicine. Suzanne Henson, a nutritionist and dietician for the College, and Calia Torres, a fellow in Behavioral Health, also assist.

The patient then must go 30 days without being readmitted to the hospital for the treatment to qualify as transitional care. The goal is for them to assimilate into their community setting and back to regular care with a primary care physician. The clinic will follow up with the patient and provide health education, a 24-hour answering service, a dedicated nurse, and walk-in care at UMC. McMillian also works to schedule an appointment with the patient’s primary care physician within two weeks.

“The clinic will serve patients as part of their patient-centered medical home,” Elsayed says. “It will provide patients with excellent care and avoid hospital readmissions at the same time.”