How an interdisciplinary care team reduces prolonged admissions among older patients with complex needs

A subset of patients cared for by the San Francisco Veterans Affairs Health Care System (SFVAHCS) are older and have complex medical, psychological, and social needs. To improve coordination and care for these patients, SFVAHCS created the Transitions Referral and Coordination team, which holds a once-weekly interdisciplinary meeting for managing geriatric complexity. Over 6 months, SFVAHCS saw an almost 40% reduction in inpatients with prolonged hospitalizations (defined as a length of stay longer than 30 days), from an average of 18 persons per week to 11 in their facility with 93 medical-surgical beds. Surveys of meeting participants highlight the value of the interdisciplinary approach. SFVAHCS is now expanding this conceptual framework to improve care for outpatients with similar needs. The authors hope their approach and findings can help other institutions similarly challenged with providing high-quality, integrated care for an increasingly common patient population.