Closing the Loop After Discharge: An IMT-Led Telephone Results Clinic in Geriatric Medicine

Introduction

Investigations requested as an inpatient were not reliably followed up in our hospital. Poor coordination of post-discharge follow-up can lead to delayed results review, threatening patient safety. This uncertainty contributes to increased length of stay, a risk factor for deconditioning and delirium. In older adults, results must be reviewed in the context of a Comprehensive Geriatric Assessment, allowing robust advanced care planning and ensuring onward investigations are tailored to the individual. We implemented a consultant-supervised, Internal Medicine Trainee (IMT)-led, telephone results clinic, across two acute geriatric wards, with the aim of shortening length of stay and improving continuity of care from hospital to community.

Methods

Retrospective data was collected for all appointments between August and December 2025, including, age, Clinical Frailty Score (CFS), results monitored, length of stay (LOS), and whether LOS was reduced. Resident doctor feedback was obtained via survey, and patient feedback was collected by telephone using structured questions.

Results

Forty-three appointments were delivered across ten sessions. Patients had a mean age of 86 years (range 72–99) and a mean CFS of 5 (range 2–7), with 70% scoring CFS 4–6. Length of stay was shortened in 33%. No patients failed to attend appointments, three were cancelled due to readmission. Results reviewed included cardiac monitoring (12/43), bloods (12/43), echocardiogram (4/43), other imaging (12/43), microbiology (2/43), and ambulatory blood pressure monitoring (1/43). No adverse patient events were identified. Two patients with CFS 6–7 benefited from advance care planning discussions. Resident doctors reported positive educational value. 100% of patients reported they found the call beneficial.

Conclusion

An IMT-led telephone results clinic is a feasible, safe, and educationally valuable model for follow-up, providing continuity of care with evidence of reduction in LOS. Next steps are expansion to front door frailty services and additional acute geriatric wards.