Post-discharge Early Assessment With a Video-visit

Prior to discharge, patients will be referred by Hospital Internal Medicine (HIM) teams to the PEARL team and screened for study eligibility. Eligible patients who provide oral consent to participate. Participants will be randomized 1:1 with comparisons between "Usual care" and "Usual care + Video-visit" arms. Participants randomized to the intervention arm will participate in a 15-20 minute Video visit (using Zoom®) with an advanced practice provider (APP; nurse practitioner or physician assistant in HIM) approximately 2-5 days after discharge. The telephone follow-up will occur 3-6 days after discharge. If a patient has a Video visit, the telephone follow-up will be scheduled for after the Video visit.

It is standard practice for HIM teams to make and coordinate outpatient appointments and activities including radiologic procedures for discharging patients. During this study, usual care will continue for patients in each arm. The intervention (Video-visit) is in addition to and not in place of the usual standard of care.

If issues/concerns beyond the scope of the video visit or telephone follow-up arise, then the PEARL APP will direct these to the discharging hospitalist team/supervising physician, or the participant's primary care provider (PCP) consistent with current standards of practice and management of post-discharge issues. Issues re-directed to the discharging hospitalist team or other providers will be documented in the Video-visit encounter. If the APP deems the clinical situation urgent or emergent, the APP will refer the patient to emergency services, or if needed ask the patient his/her location and contact 911. The APP will also immediately notify the study PI or co-PI who are both hospitalists and familiar with the practice. The APP will also notify the discharging hospitalist team.

Inclusion criteria

• Patients aged ≥18 years
• Patients discharged from a Hospital Internal Medicine service at Saint Marys Hospital
• Patients or their legally authorized representative provides consent to participate in the study
• Patients discharged home or to assisted living facility

Exclusion criteria

• Patients discharged from Hospital Service Meds 1-4 and Med 17
• Patient discharged with Care Transitions Program, or to Hospice, skilled nursing facility (SNF) or long-term acute care (LTAC) facility
• Post-procedure patients (i.e., elective hospital admission for planned intervention or procedure)
• Patient/legally authorized representative is Non-English speaking
• Patient leaves the hospital Against Medical Advice (AMA)
• No access to mobile technology/laptop/computer for post-discharge follow-up
• Patient with an active diagnosis Covid-19 infection
• Patients with a scheduled re-admission for a procedure, chemotherapy, or other treatment