S1529 Bridging the Gap: Hospitalized IBD Transition of Care Platform

Introduction: Hospitalized patients with inflammatory bowel disease (IBD) are at significant risk of rehospitalization with one significant factor is a lapse in continuity of care. Post-hospitalization follow-up in the outpatient GI clinic is a protective factor against early readmission among IBD patients. However, achieving timely follow-up remains challenging due to fragmented communication systems, scheduling delays, and insufficient coordination between inpatient and outpatient services. Our study examines the impact of a centralized communication platform (CCP) designed to improve the transition of care for hospitalized IBD patients. Methods: We conducted a retrospective analysis of patients admitted for IBD-related illnesses at a tertiary care center between July 2023 and July 2024. Patients were stratified based on the use or non-use of CCP for coordinating outpatient care following hospitalization. Details regarding demographics, IBD characteristics, hospitalization metrics, and post-discharge outcomes were collected and analyzed. Outcomes included follow-up rates, time to follow-up, new therapy initiation rates, and 30-day readmission rates. Results: Among 91 patients (median age 40, 53% male), 69% were White, 24% Latin American, and the median body mass index was 24. Ulcerative colitis accounted for 32% of cases, predominantly pancolitis (22%), while Crohn’s disease comprised 68%, with ileocolonic disease being the most common phenotype (39%). Most patients (62%) had prior treatment, and 44% were on active therapy during hospitalization. The CCP group showed a non-significant follow-up rate of 85% compared to 74% in the non-CCP group. The CCP group had a longer time to therapy initiation, with a median of 45 days (IQR: 25-62) compared to 26 days (IQR: 3-54) in the non-CCP group. This may be due to the higher rate of new therapy initiation in the CCP group (40% vs 32%), although it was not significant. The 30-day readmission (21% vs 18%, P = 0.72) and colectomy rates (4% vs 5%, P = 0.82) were similar in both groups. Conclusion: CCP was associated with improved follow-up rates and initiation of new therapies post-hospitalization for IBD patients. However, these findings were not statistically significant, likely due to the limited sample size. The existing EMR-based process, as the primary alternative to CCP, lacked transparency, with no clear understanding among stakeholders regarding its workflow or outcome. This inefficiency highlighted the need for CCP as a structured approach to improve care transitions.