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San Fran General’s Transitional Care Clinic Undergoes Makeover


San Francisco General Hospital opened its post-discharge transitional care clinic for many of the same reasons as other safety net hospitals, but through staff transitions a new role has emerged: the training of medicine residents. A nurse practitioner (NP), hired in 2007, first identified the large

number of patients who either did not have a primary care physician (PCP) or hadn’t seen one in a while, “but had a lot of complex care transition issues and were falling through the cracks,” explains Michelle Schneidermann, MD, hospitalist at SFGH.

In 2009, the NP established a “bridge clinic” five half-days a week within an existing hospital-based general medicine clinic. She encouraged referrals of any patients who needed post-discharge services and then triaged those at greatest risk into available clinic slots. But when she went on maternity leave, the clinic’s presence shrank to one half-day per week.

“It really made us take a step back and think philosophically about whether this was a necessary Band-Aid, or whether the system had changed enough that we no longer needed it,” Dr. Schneidermann says. “We found out through our assessment that things, unfortunately, hadn’t changed that much, and the need was still there for a bridge clinic.”

The “mini” bridge clinic collaborates with a new cadre of care coordinators working on discharge planning and with a new group of hospitalists to create an opportunity for medical residents to learn the challenges of care transitions hands-on. “What’s been interesting about this scaled-down version, which we call the mini-bridge clinic, is that it has made us more resourceful,” says SFGH’s Larissa Thomas, MD, MPH.

Dr. Schneidermann says the NP is planning to return in January, which will mean a new set of challenges. “We’ll need to coordinate with her around how to integrate these two approaches. But we find this is an incredible opportunity to teach future physicians about care transitions,” she says.

We found out through our assessment that things, unfortunately, hadn’t changed that much, and the need was still there for a bridge clinic.

—Michelle Schneidermann, MD, hospitalist at San Francisco General Hospital.

The challenge now, Dr. Thomas says, is to view transitional medicine in the 30 days following hospital discharge as an essential part of HM, and then build that into the training of residents. “We’re trying to reframe how we think about medicine and looking to create an integrated curriculum,” she says. “Not only will residents have the experience of the transitional care clinic, but when they’re on an inpatient rotation, they’ll be more mindful of the things that affect patient well-being after discharge.”

Larry Beresford is a freelance writer based in Oakland, Calif.

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