Grant: Travel Awards - Institute Community Support

Hospitalized patients face gaps in care, particularly after discharge. Timely post-discharge follow-up is often recommended to address problems related to the patient's transition to community. Family Medicine Groups in Quebec are multidisciplinary team-based primary care practices that were designed to better coordinate patient care. In this study, we used data from large health administrative databases representing over 300 000 patients and 600 000 hospital admissions to examine whether patients enrolled in Family Medicine Groups had equal or better rates of 30-day post-discharge physician follow-up compared to other primary care practices. We found that approximately 3 out of 5 patients saw a physician within 30 days of discharge from the hospital. Family Medicine groups had slighlty lower rates of physician follow-up compared to other primary care practices, especially for follow-up with a medical specialist. Given that timely follow-up after hospital discharge may help in reducing hospital readmission and mortality rates, future policies should work towards new ways to improve the current situation. This may include targeting aspects of innovations in team-based primary care delivery such as the role played by the nurse practitioner in post-discharge follow-up.