Abstract NS7: Driving Down Readmissions With Dynamic Discharge Follow up Team

Abstract

Introduction: Stroke patients have complex discharge needs and benefit from strong care transition models. A common care transition model is to perform discharge phone calls to eliminate gaps that may have occurred after discharge. Institutions often struggle with performing discharge phone calls - who should perform this task and what the optimal timeframe should be. Ninety percent of this institution’s 30-day readmissions occur within the first 7 days of hospital discharge, with majority due to medication misunderstanding and poor communication. Hospital readmissions have negative consequences for patients and are costly, accounting for $15 billion of Medicare dollars annually. Methods: In 2014, stroke discharges to home received a 48 hour phone call from an outpatient Registered Nurse (RN) Care Manager. In 2015, to address the medication challenges, a Pharmacist was added to the discharge follow-up team, making phone calls within 7 days of discharge. Results: In 2016, 233(61%) of the 48-hour calls by RNs connected successfully with stroke patients discharged to home. Pharmacist calls reached a higher percentage of patients discharged to home at 83% (n=321). There were 53% (n=208) receiving both calls, and 25% (n=97) of patients being unable to reach after three attempts. The resultant 30-day readmission rate has declined from 8-10% in 2013 and 2014 (when we first started tracking 30-day readmission rates) to 2-3% in 2015. This low rate has remained consistent for 2016 and 2017. Conclusion: Although post-discharge calls can be very labor intensive and time consuming, it is possible to clarify communication, ensure understanding of discharge instructions, and intervene before medication errors occur. The unique combination of an RN and Pharmacist performing the discharge phone calls has been shown to be quite effective; the RN triages acute issues, while the Pharmacist ensures accurate medication list and compliance - and ensures no medication changes were inadvertently made at a primary care provider appointment post-discharge. These interventions reduce readmissions by closing the post-discharge gaps in care that can occur, resulting in a win for both the patient and the institution.