New program offers hospital aftercare

In a bid to reduce hospital readmissions, Orlando Health on Monday opened a second outpatient center intended for patients who need follow-up care soon after leaving the hospital but can’t find it.

Orlando Health Support Team for Aftercare and Resources (STAR) Outpatient Centers step in when these patients don’t have a primary care doctor, or are unable to get in to see another doctor within seven days of discharge, said Dr. Ashley Dlugokienski, medical director of the centers.

Care at these centers is available to Orlando Health patients with or without insurance through referrals.

“This has just been a long time coming,” Dlugokienski said. “We know that there’s that gap to fill and we’ve tried to fill it by referring patients directly to the next step, but realizing how long that next step is taking. … We wanted to bridge that gap and see them faster.”

A 2015 study of over 40,000 Medicaid patients found that while most patients don’t actually benefit from early outpatient follow-up appointments after they leave the hospital, those at high risk of readmission do. That’s who this clinic targets, Dlugokienski said.

The STAR centers offer medical services including post-discharge exams and medication management. They also offer holistic services like care coordination, social support services and disease prevention education.

Whereas typically primary care follow-up visits might be 10 to 15 minutes, these are 30 to 60 minutes in order to ensure patients can get all their questions answered, Dlugokienski said.

“A lot of information told to you while you’re in the hospital, it’s overwhelming. Some patients, this is the first time they’ve even been diagnosed with any medical problem,” she said.

This service is not intended to replace primary care, and patients without a primary care doctor are referred to one. Self-pay or uninsured patients are also referred to free clinics and services such as the Primary Care Access Network.

The first STAR center opened at Orlando Health Dr. P. Phillips Hospital in August.