Abstract 294: Post-Discharge Phone Calls: Efficient Opportunity to Assess and Improve Patient Adherence to Care Plan

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Background: Transitioning from hospital to home is a common failure point in care delivery and patient adherence to a plan of care. Our post-discharge phone calls helped identify gaps (especially related to medications) and assign accountability for addressing issues. Method: We reached more than 200 patients with Acute Coronary Syndrome and Congestive Heart Failure by phone 24-48 hours after discharge between 8/2011 - 1/2012. We tested two operating models: hospital nurse with knowledge of admission (n=200) vs. clinic nurse with ongoing responsibility for managing patient (n=10 and ongoing). Callers used a standardized script and documentation form with “teach-back” methodology. Outcomes (Figure): Medications issues (65%, 107 of 165) included errors in discharge meds lists that contributed to patient misunderstandings and lack of adherence. Most (63%, 89 of 142) patients left the hospital without a scheduled follow-up appointment (revealing systematic improvement need). Callers provided teaching and reinforcement and triaged issues, avoiding at least 3 - 4 probable readmissions. Comparing two delivery models (hospital vs. clinic nurse) yielded notable differences. For both groups, calls took ∼15+ minutes (min=6, max=48). However, prep time, documentation and follow-up were significantly longer for hospital nurses (35 mins) than clinic nurses (15 mins). The hospital nurse spent more time “mining” records to understand each patient story; clinic nurses could prioritize calls and personalize content based on prior relationships with patients. Issues were quickly handled by clinic nurses in face-to-face provider interactions, whereas the hospital nurse frequently became mired in lengthy back-and-forth clinical communication. Conclusion: Analysis of post-discharge phone calls shows that some patients (new diagnoses, complicated medications regimen) may particularly benefit; however, the call represented a valuable reinforcement opportunity for all patients we reached. Optimally efficient, effective calls require: 1) Reliable patient contact information; 2) Clear record of plan of care, including accurate medications list; 3) Follow-up appointments scheduled; 4) Caller expertise with diagnoses; and 5) Caller prior relationship with the patient. Going forward, our team will continue to test clinic-based post-discharge phone calls, evaluating several key metrics including ability of patients to successfully articulate their medications and follow-up plans, % of patients who attend their follow-up appointments, readmission rates, et al.