Utility of Incorporating Behavioral Therapy in Transitions of Care Clinics

TCC (Transitions of care clinic) is a specialized clinic visit where patients present to their primary clinic after a hospital stay. TCC deploys an interprofessional team to address a gamult of patient concerns. Traditionally, TCC interprofessional team includes a nurse and a doctor. The nurse calls the patient’s house within 2 days to check up on the patient and then they schedule a clinic visit, usually within 7-14 days. However it has been proposed that addition of team members from other disciplines could contribute to better health outcomes for patients seen in TCC. We studied a TCC model with an interprofessional team of not only physicians and nurses but also pharmacists and behavioral therapists for two months. Our aim was to uncover the utility of having a behavioral health team member in TCC visits. This was a prospective study of patients who attended a TCC clinic in a residency setting. An observer collected data on the time the behavioral health provider was in the patient room and the interventions/consultations he/she provided. Data collection is ongoing. We expect to find the following: the percentage of patients within TCC who utilized some form of behavioral therapy in their TCC visits; the percentage of common interventions that were used; average time spent in each visit; average age of patients; and average number of hospitalizations per patient. We expect that these results will demonstrate how behavioral health providers function on interprofessional TCC teams.