title: Implementation of a Transition of Care Coordinator at a Military Treatment Facility.
abstract: A patient's transition from the inpatient to the outpatient setting is complex and prone to medical errors. This subsequently increases patient morbidity and cost to the healthcare system.
  
  
  METHODS
  Our quality improvement initiative used a licensed clinical social worker from within a Family Medicine residency clinic to serve as a Transitions of Care Coordinator (TOCC) with the goal of decreasing patient morbidity and system cost.
  
  
  RESULTS
  The number of documented patient contacts by our primary care office in the postdischarge period increased significantly after implementation of the TOCC (3.1% vs 40.2%, P=.01). Pearson correlation during our postimplementation period suggested an inverse relationship between contact by a TOCC and emergency department (ED) and hospital utilization rates (r=-0.68, P=.05 and r=0.062, P=.005, respectively). However, the percentage of ED visits (11.9% vs 20.8%, P=.02) and hospital readmissions (5.6% vs 13.7%, P=.01) significantly increased overall between the pre-and postimplementation periods.
  
  
  CONCLUSIONS
  The implementation of a TOCC within a military Family Medicine residency clinic significantly increased the frequency of ED visits and readmissions to the inpatient service for patients discharged from the Family Medicine inpatient service.
authors.affiliation: Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Dana
authors.initials: D
authors.lastname: Nguyen
authors.forename: Blake
authors.initials: B
authors.lastname: Busey
authors.forename: Mark
authors.initials: M
authors.lastname: Stackle
authors.forename: Tammy
authors.initials: T
authors.lastname: Donoway
authors.forename: Sarah
authors.initials: S
authors.lastname: Strickland
authors.forename: Ashley
authors.initials: A
authors.lastname: Roselle
authors.forename: Scott
authors.initials: S
authors.lastname: Hahn
authors.forename: Nick
authors.initials: N
authors.lastname: Bennett
mesh_terms: D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005194:Family Practice / Q000458:organization & administration / Q000592:standards; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D008887:Military Medicine / Q000458:organization & administration* / Q000592:standards; D008889:Military Personnel; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data; D058996:Quality Improvement; D000068217:Social Workers; D000069341:Transitional Care; D014481:United States