Collaborative Solutions to Identify Scheduling Barriers for Timely Post-Hospital Discharge Primary Care Follow-Up: A Quality Improvement Initiative
Brian Le, Wendy Simon, Jessica Zhang, Jeri Robertson, Erin DowlingBackground
Post-hospital discharge primary care follow-up visits are associated with lower readmissions but may be underutilized. Limited structured data exist on clinic-, PCP-, and patient-level barriers encountered during scheduling.
Methods
We implemented a quality improvement (QI) initiative with hospital operations and scheduling teams. Schedulers used a new in-house Epic SmartForm to document real-time barriers when scheduling post-discharge PCP follow-up. The SmartForm was refined through Plan-Do-Study-Act (PDSA) cycles to improve usability, barrier classification, and data reliability. SmartForm data were reviewed with interdisciplinary teams to guide scheduling interventions.
Results
From August 2022 through October 2024, schedulers documented 13,823 SmartForm notes for 13,420 patients. Barriers were documented in 4,024 notes (29%), with 2,896 barrier notations after excluding “reason not listed.” The most common barriers were PCP availability constraints (46%), namely accommodation requests (30%); and patient-related reasons (42%), namely patients feeling the appointment was not needed (12%). These findings informed education on protected post-hospital follow-up slots and targeted outreach to clinic directors and staff.
Discussion
Barrier identification gave leadership clearer visibility into why timely post-discharge PCP follow-up was not being scheduled. PCP availability barriers directly informed education on protected follow-up slots and clinic outreach when accommodations were needed. Patient-related barriers suggested a need for stronger communication during discharge planning.
Conclusions
Embedding an in-house SmartForm within scheduler workflows and refining it through PDSA cycles enabled structured, real-time capture of scheduling barriers. Schedulers are key contributors to care transitions and systematic monitoring of barriers can support data-driven QI efforts to improve timely post-discharge PCP follow-up.