New evidence that primary care visits soon after hospitalization are associated with fewer readmissions

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Date
January 25, 2019
April 1, 2021
New brief: Lessons from our maternal health care management pilot
In this newly published brief, two Camden Coalition care team members share lessons from Camden Delivers, our maternal health care management pilot.
Michelle Adyniec, RN, BSN, and Jessica Cordero, MA, CHW
March 25, 2021
How can state officials help dismantle structural racism? Lessons from New Jersey
Read the adapted welcome remarks by our CEO Kathleen Noonan for “Dismantling Systemic Racism in Pennsylvania State Agencies".
Kathleen Noonan
March 10, 2021
Addressing concerns about COVID-19 variant strains
Dr. Jubril Oyeyemi addresses concerns about the new variant strains of the COVID-19 virus in this short video.
Jubril Oyeyemi
February 19, 2021
Using the complex care core competencies to support treatment for substance use disorders
Our National Center and Clinical Redesign teams worked together to adapt the complex care core competencies for two NJ SUD navigation programs.
Dayna Fondell, Shelby Kehoe, Rebecca Koppel, Mouy Pan
February 8, 2021
Camden Promise Neighborhood’s School Based Health Center fosters health and learning
Camden Promise Neighborhood operates a health clinic within a local school to address the health needs of its students.
Evelyne Kane and Aaron Truchil of the Camden Coalition; Candice Dias and Louis Klein of Camden Promise Neighborhood at Center For Family Services
January 27, 2021
Addressing COVID-19 vaccine concerns
Dr. Jubril Oyeyemi addresses concerns he is hearing about the COVID vaccine in this short video!
Jubril Oyeyemi

By Dawn Wiest, Qiang Yang, Carter Wilson, and Natasha Dravid

As part of the Camden Coalition’s ongoing quality improvement efforts, we evaluated our 7-Day Pledge program to learn about the relationship between timely follow-up appointments with primary care and avoidable readmissions. 7-Day Pledge is a citywide program to reduce hospital readmissions by facilitating primary care follow-up appointments within seven days of patients leaving the hospital. We do this by engaging directly with patients and primary care providers to reduce well-known barriers like difficulty scheduling appointments and transportation, and we provide enhanced reimbursement to providers to prioritize patients recently discharged from the hospital.

The results of our analysis were published today in JAMA Network Open. We compared patients who had a primary care follow-up within seven days with patients who had similar clinical and demographic characteristics but who had a later or no follow-up appointment. We found that patients who had primary care appointments within seven days of hospital discharge had a lower number of 30- and 90-day hospital readmissions.

Infographic showing a reduction in hospital readmissions after both 30 and 90 days when patients followed up with primary care providers within seven days of hospital discharge.

“These results show that primary care practices’ commitment to reducing hospital readmissions is making real change for people in Camden,” said Camden Coalition CEO Kathleen Noonan. “We’re excited to build on this evidence and strengthen our partnerships with healthcare providers, health systems, and community members throughout the region.”

Our evaluation highlights the importance of timely primary care follow-up appointments and shows the value of collaboration. The 7-Day Pledge relies on our partnerships with primary care practices in and around Camden, including: CAMcare, Cooper Ambulatory Pediatrics, Cooper Internal Medicine, Cooper Family Medicine, Fairview Village Family Practice, Osborn Family Health Center, Project H.O.P.E., Reliance Medical Group, and Virtua Primary Care. As Camden Coalition Health Information Exchange participants, Cooper University Health Care, Jefferson Health’s three New Jersey hospitals, Lourdes Health System, and Virtua Health provide us with the data we need to run the 7-Day Pledge.

Now that we know that rapid connection to primary care helps lower readmissions for a general adult population, our next step is to learn more about which patients will benefit most from the 7-Day Pledge. This will help us target our work so we can help people most effectively and provide a return on investment.

Read the results of the 7-Day Pledge evaluation in JAMA Network Open.

Read our 7-Day Pledge quality improvement brief outlining our evaluation results.

Read our 7-Day Pledge clinical redesign brief to learn about the citywide partnership that powers the program.

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