Within the hospital, every aspect of a patient’s care is expertly managed by the care team—from diet to medications to pain. Once discharged, however, much of this responsibility falls squarely on the individual. This is where things tend to fall apart, according to Dharmini Shah Pandya, MD, Medical Director of the Multi-Visit Patient (MVP) Clinic at Temple University Hospital.
“As providers, we need to be thinking about more than disease management when striving to keep patients healthy and at home,” explains Dr. Shah Pandya, Associate Professor of Clinical Medicine at the Lewis Katz School of Medicine at Temple University. “Can the patient access their medication, and do they understand when and how to take it? What about their diet—does it affect their disease process? And then there are other things such as housing insecurity and transportation. These social determinants must all factor into a person’s care.”
Enter the MVP Clinic. Initially created as a means to reduce readmissions for heart failure, the MVP Clinic is proving that a little support can go a long way in improving patient outcomes. Building meaningful relationships with community health workers, patients can become more engaged in the continuum of their care.
Since the launch of this pilot program in 2020 until January 4, 2022, the clinic has seen around 380 patients and has reduced Emergency Department visits by about 40 percent and readmissions by about 45 percent. What’s more, patients are more engaged in their health care and are visiting outpatient clinics—with an increased outpatient utilization rate of 46 percent. These results have led the clinic to expand its services to patients with other medically complex conditions, such as diabetes.
Any individual – insured or uninsured – who has been readmitted to the hospital or visited the Emergency Department within 90 days of hospital discharge is considered a candidate for the MVP Clinic. Sometimes, an inpatient provider identifies and refers the patient to the clinic. Other times, the patient is identified though an Epic alert or a conversation with a community health worker.
“When a qualifying patient is readmitted, the community health worker will visit them at the bedside to screen for social determinants and introduce the MVP Clinic,” explains Dr. Shah Pandya. “The community health worker continues to follow the patient throughout their hospitalization. At discharge, they return to the bedside to provide the patient with an appointment and prearranged transportation if this is something that was identified as a challenge during screening.”
The day before the appointment, which usually takes place between 4 and 7 days after discharge, the community health worker will remind the patient with a phone call. They then meet the patient at the entrance to the Boyer Pavilion to see them to the clinic, currently located in the Temple Heart & Vascular Institute.
“We use the first clinic visit to understand how the patient is managing and to identify what gaps exist in their care since discharge from the hospital,” says Dr. Shah Pandya. “This is our opportunity to help them close these.”
While some patients can be transitioned back to their primary care doctor after the first visit, Dr. Shah Pandya explains that those with greater challenges or who don’t have a primary care physician are followed by the clinic for up to a year.
Given the clinic’s early success, Dr. Shah Pandya is hoping it will become the Health System’s model for improving the quality of outpatient care in the future.
“Ideally, we will see the number of referrals increase – particularly from the Emergency Department where we have the opportunity to capture lower-acuity patients,” she says. “I also see an opportunity for greater collaboration with Temple’s primary care providers and area practices.”