“I’m lost. What city is this?” asked the traveler.

“Вы – здесь,” the clerk replied.

“I don’t understand.”


“Moscow? I overslept my train stop. I don’t know where I’m going, or how to get there. I don’t have a schedule, hotel reservations, a map, a Russian dictionary, or currency. I do have a splitting headache. Can you help me?”

“Я сожалею. Я не туристический агент. I’m sorry. I am not a travel agent.”

Discharged safety net patients are much like our poor traveler. They are frequently released with:

  • New diagnoses they don’t understand (foreign language)
  • Lack of information regarding next steps (no map)
  • No certainty referrals will be accepted or when appointments will be given (no schedule)
  • No patient-centered medical home (PCMH) follow-up appointments (no hotel reservations)
  • Inadequate funds (no currency)

Because of this, they may feel stressed, alone, unsafe, or experience physical discomfort. They need a travel agent to help them navigate the health care system, explain diagnoses, prepare for next steps, and assist with post-discharge diagnostic studies and specialty referrals.

PCMH’s Link Patients With Needed Resources

This year’s National Patient Safety Foundation Patient Safety Awareness Week (March 2-8) theme is “Navigate Your Health…Safely.” This applies to care transitions between inpatient and outpatient settings.

All discharged patients benefit from a smooth, timely return to their PCMH for general care and navigation services. “Super-utilizers” (frequent ED and inpatient visits) particularly benefit, as highlighted in the recent Essential Hospitals Engagement Network webinar by the Contra Costa Regional Medical Center. The PCMH links them with:

  • Mental health care
  • Specialty care
  • Addiction treatment
  • Hospice
  • Community support

The PCMH can only help patients navigate post-discharge care if they know about discharged patients, just as a travel agent can only help customers they know about.

Pilot Project Aims to Prevent Avoidable Rescue-Care Visits

With grant funding from the Blue Shield of California Foundation and the Center for Care Innovations, the Los Angeles County Department of Health Services (DHS) aims to prevent avoidable rescue-care visits through:

  • Automatically notifying PCMHs when their patient is:
    • In the ED
    • Discharged from the ED
    • Admitted inpatient
    • Discharged from inpatient

We also will email the patient’s PCMH’s care manager and email them information, including the patient’s name, medical record number, event type, medical home, primary care physician, and discharge summary, thereby creating a “one-stop shop” with all information needed to coordinate post-discharge care.

  • Engaging discharged patients in post-discharge care via texting. Patients will receive an interactive text message asking:
    • Do you have a primary care or specialty follow-up appointment in the next seven days?
    • Do you have enough medications to last until your next appointment?

Responses will post to a HIPAA-secure website accessible by the care manager. If the answer to either question is “yes,” the care manager will contact the patient for follow-up care or prescriptions.

Improved Coordination as a Solution

Gaps in communication and care transitions are all-too-common in the health care system. Such missteps result in avoidable admissions, readmissions, and lapses in care, which may lead to patient and provider dissatisfaction and high health care costs.

While still in the testing stages, we think this system will help providers better coordinate care for each PCMH patient, as well as make it easier for patients to navigate the system.