Mary E. Schroeder

Background Persons of low socioeconomic status are overrepresented in the firearm injury patient population and may experience challenges in accessing complex outpatient health systems. Consequently, outpatient care for these patients is plagued by poor follow-up and increased emergency department (ED) utilization. We developed a Post Discharge Care Team (PDCT) consisting of a dedicated trauma nurse navigator and medical social worker to bridge the gap between hospital discharge and outpatient care to improve recovery. Methods Adult firearm injury survivors admitted to the trauma service were randomized 1:1 to receive either PDCT services or standard of care (SOC) workflows. The PDCT nurse provided education and set expectations regarding injuries, wound care, and outpatient follow up. The PDCT social worker performed a comprehensive assessment to identify concerns including housing and financial instability, food insecurity, or transportation issues. The primary outcome was ED utilization, with secondary outcomes including readmissions and overall healthcare costs compared between groups. Results In the first six months of the study, a total of 44 patients were randomized to PDCT and 47 to SOC. There were 10 patients who visited the ED in the PDCT group compared to 16 in the SOC group (p = 0.23) for a total of 14 and 23 ED visits, respectively. There were 14 patients in the PDCT and 11 patients in the SOC groups who were readmitted (p = 0.31), but the PDCT group was readmitted for 27.9 fewer hospital days. After accounting for programmatic costs, the PDCT had a hospital savings of $34,542.71. Conclusion A collaborative, specialized Post Discharge Care Team for firearm injury survivors consisting of a dedicated trauma nurse navigator and medical social worker decreased outpatient ED utilization, readmission days, and was cost effective. Trauma centers with high volumes of penetrating trauma should consider a similar model to improve outpatient care for firearm injury survivors. Level of Evidence Original Research, Quality Improvement, 2