“It’s bigger than just the visit”: A hospital follow-up initiative to address social determinants of health and promote high quality transitions of care Nancy M. Denizard-Thompson, MD 1, Kirsten B. Feiereisel, MD 1 1 Department of Internal Medicine, Section on General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina Statement of Problem Although much work has been done to improve time to hospital follow-up visit, the quality and breadth of these visits is often lacking. Objectives 1.To decrease variability of hospital follow-up visits among residents in clinic through a standardized template 2.To train residents on the key components of hospital follow–up visits and social determinants of health 3.To improve quality of hospital follow-up visits by addressing key issues that impact readmission and safe transitions back to the community and medical home Intervention  The intervention was implemented at two underserved internal medicine resident clinics at an academic medical center. Results  A preliminary chart audit was performed reviewing 10 charts which utilized the note template and 10 charts that did not utilize the note template. Key Lessons for Dissemination 1.The residents demonstrated steady growth in usage of the template and it is gaining persistent attending and resident enthusiasm. 2.A standardized template incorporating key social determinants of health and highlighting clinical areas of concern for patients with high readmission rates promotes safe transitions of care. 3.Having a separate hospital follow-up clinic with longer appointment times allowed residents to improve quality and breadth of hospital follow-up visits and improved documentation. ©Creative Communications Wake Forest Baptist Medical Center Permission is granted for use when printed by Creative Communications. All other uses strictly prohibited. ©Creative Communications Wake Forest Baptist Medical Center Permission is granted for use when printed by Creative Communications. All other uses strictly prohibited. Measures of success  Integration of hospital follow-up template into resident practice  Increased documentation of domains emphasized in template  Recognition by residents and faculty preceptors that the template facilitates identification of relevant issues that may be otherwise missed  Awareness that issues such as transportation, functional status, family support, and social networks are key components to assess to facilitate a safe transition back into the community Hospital f/u template Incorporates access to medications, functional status, social support, and home care needs Emphasizes medication reconciliation, pending labs, and key studies Prompts for the transition of care billing codes. New Hospital f/u resident clinics Longer visit slots of min At one clinic site occurs during off week of Hospitalist rotation Interdisciplinary team support with pharmacist, mental health counselor, social worker, care manager depending on the site Figure 1: Hospital follow up template Key Component Without Template With Template Functional Status20%100% Social Network20%100% Transportation0%90% Home Services20%100% Route to PCP0%70% Route to Key Providers 0%40% Table 1: Early impact of template on documentation Supported by a grant through the North Carolina Chapter of the ACP