At the University of California, San Diego Health, we implemented a hospital medicine physician-led virtual transitions of care (VToC) clinic, focused on postdischarge clinical management, medication reconciliation, primary care provider (PCP) repatriation, and specialty care navigation, with the aim of reducing repeat hospitalization.

Based on internal pilot data showing a favorable readmission impact for patients with moderate risk of readmission, we created a criteria-based order to trigger referral for patients (aged 18 years and older) discharged from the hospital medicine service line. The discharging providers were automatically prompted at discharge to refer patients to the clinic if patients had a LACE+ index (a readmission risk prediction index based on length of stay, acuity of admission, comorbidities, and emergency department visit history) between 50 and 75 [7]. Patients with LACE+ scores outside this range could be referred at provider discretion. Patients were excluded from appointment scheduling if they were discharged to a care facility or hospice or had an existing PCP appointment within 7 days of discharge.

The virtual clinic was supported by 12 hospitalists, 2 medical assistants, 1 pharmacist and an on-demand interpreter service. Medical assistants contacted eligible patients to schedule web-based video visits. VToC visits were occasionally converted to telephone encounters when patients faced technical barriers, which occurred in fewer than 5% of cases and thus were not considered a distinct comparison group for analysis. Patients received phone call reminders 1 business day prior to scheduled appointments. Pharmacists conducted previsit medication reviews to identify fill history gaps, dosing inconsistencies, and potential drug-drug interactions. Note templates guided VToC providers in addressing medication management, social determinants of health, barriers to follow-up, and care coordination. A standardized electronic handoff was routed to the patient’s PCP and relevant specialists summarizing the reason for hospitalization, follow-up needs, and timing recommendations. Additionally, post-VToC visit communication was sent to the discharging hospitalist to highlight potential care lapses and support quality improvement efforts.

Data were collected from the electronic health records using standard SQL queries. These included demographics (ages grouped as <45, 45-64, and ≥65 years; sex; and race and ethnicity); VToC status (yes or no); PCP (University of California San Diego or other); LACE+ score (<50, 50-75, or >75); and 30-day all-cause readmission. Patient characteristics were analyzed by VToC status (yes or no). A VToC status of “no” indicates patients who were discharged from the medicine service line to home and not seen in our clinic (because they did not meet eligibility criteria or could not be reached). Patients were excluded from analysis if they had missing demographic or clinical data. Readmission rates were analyzed for VToC status and by LACE+ score. Chi-square analysis was used to compare characteristics by VToC status with a P<.05 considered significant. Readmission rates (%) by VToC status stratified by LACE+ decile are reported. Error bars were calculated using 95% CIs. A multivariable logistic regression analysis was performed to assess independent associations with unplanned hospital readmission. Variables included in the model included age group, sex, race and ethnicity, PCP affiliation (UCSD versus non-UCSD), LACE+ score, and VToC enrollment. All analyses were conducted using the SPSS Statistics software suite (version 27.0; IBM Corporation).

This study was conducted in an Institutional Review Board–exempt fashion in accordance with the ethical standards of the University of California San Diego Human Research Protection Program and the Office for Human Research Protections and adhered to the Helsinki Declaration of 1975, as revised in 2000.