Reducing Hospital Readmissions With Simple Post-Discharge Calls (part 2)

Nurse calls patient for a follow-up after they've been discharged from the hospital.

Reducing Hospital Readmissions With Simple Post-Discharge Calls (part 2)

(Continued from part 1 of 2.)

Post-Discharge Patient Education

Often, a patient is readmitted because they didn’t follow the correct medication regimen, lacked understanding of the treatment plan, or failed to follow up with their primary care physician after discharge.

Ideally, patients receive thorough education about medication regimens and treatment plans throughout their stay and at the time of discharge. However, literacy and comprehension rates vary across patient populations, and patients don’t always understand written or verbal discharge instructions.

Additionally, at the time of discharge, patients are often preoccupied with the logistics and excitement of going home. Attempts at patient education might not be well received, no matter how well delivered. Once patients have arrived at home, the complexity of managing their new medications and daily routines on their own becomes much more apparent.

Several studies have found that other factors, including the patient’s social support network, marital status, gender, and income can affect a patient’s ability to follow discharge instructions and manage their care at home.

Whether it’s addressing a lack of comprehension regarding a patient’s treatment plan or addressing a lack of support in enacting that treatment plan, a post-discharge phone call can provide a way for hospitals to help patients stay well at home.

Using Calls To Reduce Readmissions

Hospitals have many opportunities throughout a patient’s healthcare journey to reduce the chance of readmission. One commonly cited way to reduce readmissions is by improving patient education around managing their care after discharge.

Specifically, implementing a post-discharge phone call to review medication regimens and treatment plans, discuss symptoms and other concerns, and check in on home health services and follow-up appointments has been shown to help reduce readmission rates.

A paper published in the American Journal of Medicine in 2001 found that when pharmacists called patients 2 days after discharge to review whether they had obtained and understood how to take their medications, patients were much less likely to visit the emergency department within 30 days of discharge. Ten percent of those who received a phone call from a pharmacist went to the ED, compared to 24% of patients who did not receive a call.

In another program, IPC The Hospitalist Company (IPC) tested the effect of post-discharge call center outreach on readmission rates. Nurses at the IPC call center called 350,000 discharged patients from October 2010 through September 2011. During the calls, nurses talked through each patient’s symptoms, medications, home health services, and follow-up appointments. The nurses answered patient questions about discharge instructions and, if the patient had a serious medical need, contacted the patient’s hospitalist or primary care physician.

Nurses successfully reached 30% of patients, and it was estimated that the program prevented 1,782 avoidable readmissions over the course of a year.

Setting Up A Post-Discharge Call Program

Research suggests that the best time for a post-discharge call is within the first 2-3 days after a patient arrives home. At this point, the patient has had the opportunity to settle in, fill medications, make follow-up appointments, and it is still early enough for a nurse call to make an impact. It’s likely many patients won’t answer on the first try, so nurses should plan to call more than once in this timeframe for most patients.

The first step in setting up a post-discharge call program is to ensure that call center staff have the best number to reach each patient. Sometimes the number in the patient’s record is not the same as their home or cell phone number. IPC The Hospitalist Company found that by asking patients for the best number to reach them or their caretaker, they were able to increase their successful call rate from 30% to more than 40% of discharged patients.

Customized Care Call Scripts

Providing nurses with diagnosis-specific scripts can help make care calls more efficient and effective, as many conditions have standard red flags nurses should check in on, such as weight gain after discharge for heart failure. Virtually any type of script can be easily created, including some common scripts for post-surgery, diabetic, and pediatric post-discharge calls. Setting up a unique script with detailed questions for each, helps to ensure patients understand discharge instructions, address any medication questions, and help ensure the patients are not experiencing symptoms that would cause them to be readmitted.

Nurses should also have access to physicians’ discharge notes to review patient-specific follow-ups. Physician discharge notes will need to be completed in a timely manner to give nurses the information they need for the calls.

To supplement the post-discharge nurse phone call, organizations can also use HL7 integration to receive discharge notifications and set up automated appointment reminder calls. This helps increase the likelihood that patients make it to their appointments, and receive the prescribed follow-up care.

Conclusion

To avoid the penalties and help patients to stay healthy at home, hospitals can leverage call centers and post-discharge phone calls with customized scripts to check in on symptoms, review medications and treatment plans, and remind patients of follow-up appointments. Studies suggest that such measures reduce the rate of readmissions. For hospitals, implementing a discharge call center program can help avoid or reduce Medicare readmission rate penalties. For patients, the program can improve their post-discharge care management and health.

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