Virtual integrated clinic: a post-discharge follow-up service

University Hospital of North Staffordshire

  • Project led by University Hospital of North Staffordshire in partnership with Stoke Clinical Commissioning Group.
  • Focused on the acute care discharge and follow-up process.
  • Aimed to provide more effective integration between primary and secondary care for patients being discharged from hospital.
  • Set up a virtual clinic, staffed by a GP and a consultant physician, to address queries from primary care practitioners, and to complete and follow up on inpatient investigations.

The University Hospital of North Staffordshire project team set up a virtual clinic to provide more effective integration between primary and secondary care for patients being discharged from hospital.

Staffed by a GP and a consultant physician, with support from an administrator, the role of the clinic was to:

  • review notes and results for discharged patients
  • address any queries raised by primary care practitioners after the patient had been discharged
  • complete and follow up on investigations requested while the patient was in hospital.

The aims of the project were to:

  • speed up discharge for patients and prevent patients from having to stay in hospital unnecessarily
  • provide GPs with a single, direct contact for addressing queries about patients after they have been discharged
  • make sure that patient care plans are not mislaid between primary and secondary care
  • engage the primary and secondary care sectors in planning post-discharge care.

Who was involved

The project was led by two consultant physicians. Other team members included the trust’s chief operating officer, associate director for medicine and lead for transformation delivery, a representative from the research and development department, and a local GP.

A GP and a consultant physician both worked in the clinic 7 hours per week.

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