Postdischarge Phone Calls Research Articles

Integrating Residents – Organizational Quality Metric of reducing 30-day readmission of patients with acute decompensated heart failure (Interdisciplinary QI project)

Introduction: Hospital readmissions post-discharge for congestive heart failure (CHF) pose a significant burden on patients and healthcare systems, indicating potential gaps in care quality. The 2022 heart failure guidelines advocate for structured workflows to address this issue. Despite this, McLaren Flint Hospital witnessed a rise in 30-day readmissions for CHF exacerbation, highlighting the need for intervention. To tackle this challenge, our resident-faculty Quality Improvement (QI) team has partnered with institutional QI/Patient Safety (PS) initiatives. Our goal is to establish a coordinated approach involving various healthcare professionals to optimize the discharge process and transition of care for CHF patients at McLaren Flint Hospital. Methods and Materials: Our intervention comprises two crucial tools: a CHF workflow sheet and a CHF medication sheet. The workflow begins with patient identification through daily census reports. Upon discharge, nurses implement the CHF medication sheet, with medications prescribed by medical floor doctors. Pharmacists and dietitians review and educate patients about medications and dietary considerations, respectively. Additionally, case managers organize post-discharge phone calls and appointments with primary care physicians within 48 to 72 hours and 7 days, respectively. Weekly reports on patients requiring cardiac rehabilitation are also dispatched. Plan-Do-Study-Act (PDSA) Toolkit guides our implementation, allowing for continuous improvement and adaptation. Results: The initial implementation phase commenced on March 6th, 2024. Nursing staff are well-versed in the workflow, and CHF medication forms are readily accessible in patient charts. However, challenges in timely medication reconciliation and orders pose operational hurdles, necessitating resolution. Ongoing evaluation will provide more comprehensive results approximately two months post-completion of the first PDSA cycle. Conclusion: Our initiative aims to address areas for improvement in reducing 30-day readmission rates post-CHF exacerbation at McLaren Flint Hospital. Utilizing the PDSA cycle toolkit, we will monitor outcomes and refine our process accordingly.

547 ADHD and Burn Injuries: The Hidden Readmission Risk in Pediatric Patients

Abstract Introduction Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with the hallmark characteristics of poor impulse control, inattention, hyperactivity, and other cognitive dysfunction; as a consequence, children with ADHD are at an increased risk of burn injury. We hypothesized that pediatric burn patients with ADHD have a higher rate of unplanned readmission compared to patients without a diagnosis of ADHD. Methods We analyzed the Nationwide Readmission Database (01/2018 - 10/2018) to compare 60-days readmission rates in children (< 18 yo) with and without a diagnosis of ADHD who were treated for burn injuries on their index admission. Weighted multiple logistic regression was performed to obtain population estimates of odds ratios (OR), adjusting for patients’ demographics, burn severity and location, comorbidities, socioeconomic status, other psychiatric illnesses, and burn treatment on index admission. Results Our cohort included 1,879 children with burn injury. Of these, 79 (4.2%) had a diagnosis of ADHD. ADHD patients were more likely to be male (86.1% vs 59.8%, p=0.0002 ) and older (11.6 ± 3.7 vs 5.4 ± 5.3 years, p=0.0001). Children with ADHD were more likely to have other psychiatric diagnoses (26.6% vs 3.8%), specifically obsessive compulsive disorder (2.5% vs 0%, p=0.004), and other developmental disorders (15.2% vs 1.6%, p=0.0002). Patients with ADHD were more likely to be readmitted within 60 days of their index admission (15.2% vs. 4.8%, p=0.002). On weighted multiple regression analysis, ADHD had a higher adjusted odds ratio of readmission (OR: 2.66, 95%CI: 1.13-6.29). Conclusions Children with ADHD have a higher adjusted risk of readmission following thermal injury. This is potentially due to higher barriers to compliance with wound care, physical therapy, and scar management. Targeted discharge planning for patients with ADHD, including scheduled short-term follow-up appointments, home nursing assistance, and post-discharge phone calls, may potentially lower readmission risks in this vulnerable population. Applicability of Research to Practice Pediatric patients with ADHD are at higher than average risk for unplanned readmission within 60 days of discharge. Pediatric burn centers have the opportunity to adjust their post-discharge practice with these high-risk patients to decrease this risk. Interventions could include: more frequent clinic follow-up, longer duration with outpatient therapy, and additional coaching for caretakers on how to improve patient compliance.

Coordinated patient outreach for reduction of unplanned postoperative 30-day readmission

ObjectiveThirty-day readmission rates after surgery are being increasingly used as a quality performance metric. Readmission rates in vascular surgery are frequently reported to be higher than other surgical specialties, and many coordinated efforts have been developed at local and national levels to reduce avoidable readmissions. MethodsWe constructed a multi-pronged readmission reduction quality improvement (QI) initiative aimed at addressing the clinical drivers of readmission after vascular surgery. Proposed interventions were implemented in Plan-Do-Study-Act (PDSA) cycles. Interventions aimed to improve patient communication and included post-discharge phone calls; mandatory follow-up before 2 weeks, with in-person visits required for all groin incisions and ischemic lower extremity wounds; and protocolized distribution of “calling cards,” which contained emergency and routine contact information. The primary outcome measure was 30-day readmission rate. ResultsAfter implementation of a multi-modal QI initiative, there was a statistically significant decrease in the 30-day readmission rate, from 14.1% to 8.2% (P = .02). A slightly higher percentage of readmissions, 57%, occurred within the first 2 weeks of discharge. ConclusionsThe consensus-driven development and implementation of a QI protocol to reduce 30-day readmission, based on increased patient communication and more standardized patient follow-up, showed promising results at our institution. Further efforts to improve readmission should focus on decreasing barriers to patient-provider communication after discharge.

Feasibility and safety of planned early discharge following laparotomy in gynecologic oncology with enhanced recovery protocol including opioid-sparing anesthesia.

This study aims to evaluate the feasibility and safety of planned postoperative day 1 discharge (PPOD1) among patients who undergo laparotomy (XL) in the department of gynecology oncology utilizing a modified enhanced recovery after surgery (ERAS) protocol including opioid-sparing anesthesia (OSA) and defined discharge criteria. Patients undergoing XL and minimally invasive surgery (MIS) were enrolled in this prospective, observational cohort study after the departmental implementation of a modified ERAS protocol. The primary outcome was quality of life (QoL) using SF36, PROMIS GI, and ICIQ-FLUTS at baseline and 2- and 6-week postoperative visits. Statistical significance was assessed using the two-tailed Student's t-test and non-parametric Mann-Whitney two-sample test. Of the 141 subjects, no significant demographic differences were observed between the XL group and the MIS group. The majority of subjects, 84.7% (61), in the XL group had gynecologic malignancy [vs. MIS group; 21 (29.2%), p < 0.001]. All patients tolerated OSA. The XL group required higher intraoperative opioids [7.1 ± 9.2 morphine milligram equivalents (MME) vs. 3.9 ± 6.9 MME, p = 0.02] and longer surgical time (114.2 ± 41 min vs. 96.8 ± 32.1 min, p = 0.006). No significant difference was noted in the opioid requirements at the immediate postoperative phase and the rest of the postoperative day (POD) 0 or POD 1. In the XL group, 69 patients (73.6%) were successfully discharged home on POD1. There was no increase in the PROMIS score at 2 and 6 weeks compared to the preoperative phase. The readmission rates within 30 days after surgery (XL 4.2% vs. MIS 1.4%, p = 0.62), rates of surgical site infection (XL 0% vs. MIS 2.8%, p = 0.24), and mean number of post-discharge phone calls (0 vs. 0, p = 0.41) were comparable between the two groups. Although QoL scores were significantly lower than baseline in four of the nine QoL domains at 2 weeks post-laparotomy, all except physical health recovered by the 6-week time point. PPOD1 is a safe and feasible strategy for XL performed in the gynecologic oncology department. PPOD1 did not increase opioid requirements, readmission rates compared to MIS, and patient-reported constipation and nausea/vomiting compared to the preoperative phase.

Impact of Pharmacist Integration Into Primary Care on Reimbursement for Hospital Follow-Up Visits.

The financial and clinical impact of transitional care management (TCM) outcomes through pharmacist integration within primary care is not well described. The primary objective of this study was to determine the financial impact of pharmacist conducted post-discharge phone calls. The secondary objectives included readmission rates and number of interventions. A computer-generated list identified patients discharged from St. Joseph's/Candler Health System (SJ/C) with a listed primary care provider within the SJ/C Primary Care Medical Group at Eisenhower from November 1, 2019 to April 30, 2020. Eligible patients who received a post-discharge phone call from a pharmacist were compared to those who received a call by another staff member. Data was collected regarding the financial impact of pharmacist conducted post-discharge phone calls. Readmission rates and medication related interventions were also assessed. There were 104 patients discharged meeting criteria. Twenty-four patients were contacted by a pharmacist resulting in 20 subsequent hospital follow up appointments scheduled with the provider. Total amount billed for those appointments was $4220 (average of $211 per visit). Twenty-five calls were made by non-pharmacist staff with 23 appointments scheduled. Total amount billed for those appointments was $2445 (average of $106 per visit). Increased reimbursement was generated by a qualifying 2-way communication by the pharmacist as outlined by Center for Medicaid and Medicare Services enabling providers to bill for a TCM visit versus standard office visit. Pharmacists made 33 clinical interventions including medication reconciliation, medication procurement, referrals, lab orders, and education. One intervention was made by non-pharmacist staff. The 30-day readmission rate for pharmacist contacted patients was 8% versus 12% for non-pharmacist contacted patients. Pharmacist involvement in TCM while integrated into a primary care office is previously not well described. This data highlights an opportunity for pharmacists to demonstrate sustainability and improved outcomes related to TCM.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection.

Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity. This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity. Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively. This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls

An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Impact of post-discharge phone calls on non-urgent hospital returns < 90days following primary bariatric surgery.

IntroductionQuality of care delivery may improve patient outcomes post-bariatric surgery. We examined the quality of post-discharge phone calls (PhDC) to determine the impact on early (< 90 day) non-urgent hospital returns (NUHR) following primary bariatric surgery.MethodsA retrospective review was performed on patients who underwent Roux-en-Y-gastric bypass (RYGB) or sleeve gastrectomy (SG) in 2019. Patients were compared between presence of care coaching (Jan–June 2019) versus no care coaching (July–Dec 2019). Baseline demographics, comorbidities, psychiatric history, and PhDC were collected. Index PhDCs were coded for completeness using a scoring system and rated by call quality. Patients were stratified into NUHR versus control group (Never returns [NR]). Primary analysis examined the impact of PhDC on NUHR. Sub-analysis examined the impact of call quality. Univariate analysis was performed using Chi-square or Fisher’s exact tests. Multivariate analysis (MVA) was used to determine predictors of NUHR. A p-value of ≤ 0.05 was statistically significant.ResultsA total of 359 patients were included. Compared to the NR group (n = 294), NUHRs (n = 65) were more likely to be younger (41.3 + 12.1 versus 45.0 + 10.8 years, p = 0.024), with baseline anxiety (41.5% versus 23.5%, p = 0.003), and undergo RYGB (73.3% versus 57.8%, p = 0.031). There was a significant difference in number of PhDC in the NUHR and NR groups (p = 0.0206). Care-coached patients had significantly higher rates of high-quality phone calls (p < 0.0001) compared to non-care-coached patients. MVA demonstrated younger age (OR = 0.97, CI: 0.95–1.00; p = 0.023), anxiety (OR = 2.09, CI: 1.17–3.73; p = 0.012), RYGB (OR = 1.88, CI: 1.02–3.45; p = 0.042), and > 50% call quality versus no PhDC (OR = 0.45, CI: 0.25–0.83; p = 0.010) were independently associated with NUHRs.ConclusionHigh-quality PhDCs may play a role in mitigating NUHRs. Care coaching represents a potential intervention to decrease high rates of NUHR in primary bariatric surgery patients.

Just text me: A feasibility study of postoperative texting evaluations for gynecologic oncology patients (291)

<b>Objectives:</b> Postoperative recovery is a stressful time for patients. As part of the standard of care, postoperative gynecologic oncology patients at the University of Pennsylvania Health System receive post-discharge phone calls by gynecologic oncology nurses to evaluate and recommend intervention as needed during patients' postoperative recovery. Given the high clinical volume, we aimed to determine if an automated text messaging program and healthcare innovation strategies, in lieu of routine telephonic nursing evaluations, could provide postoperative patient assessments that were comprehensive, were satisfactory to patients, and decreased provider clinical workload. <b>Methods:</b> English speaking patients undergoing surgery with four providers in the Division of Gynecologic Oncology at the University of Pennsylvania Health System from February 2021 to June 2021 were eligible for enrollment. Patients were offered routine telephonic evaluations by the gynecologic oncology nurses versus text message-based evaluations. Enrolled patients were texted 48 hours following discharge using an algorithm based on the Division's routine telephonic script. A "fake back end", i.e. a care team member who sent and responded to patient text messages, was utilized given the pilot nature of this study. Patients who did not respond were called by the nursing team to complete the remaining questions for evaluation. Patients with responses requiring further assessment were called by the nursing team for triage. Over the course of the pilot study, the algorithm was edited in response to patient and provider feedback. This program was approved by the Penn Medicine Institutional Review Board Quality Initiative and supported by the Center for Health Care Innovation. <b>Results:</b> Sixty-nine patients were approached for the program with 56 patients enrolling. Median age of enrollees was 54 years (IQR= 45.1-62.5). Basic demographics are provided in Table 1. The most common reason for declining the program was patient preference of telephone call. Of enrollees, 41 (73%) initiated the program. Of the 41 active enrollees, 18 (44%) completed the entire algorithm. Median time to completion of the algorithm was 34 (IQR 20-81) minutes. The 18 completed algorithms saved an estimated 4.5 hours of provider time. Reasons for non-completion were: 5 (22%) response indicated need for provider assessment, 3 (13%) algorithm error, and 15 (65%) patient non-response. Of the 17 enrollees who answered "On a scale of 0-10, how likely are you to recommend this texting program to a friend if they were getting the same procedure as you?" there were 13 promoters (9-10), 1 neutral participant (7-8), and 3 detractors (6 or less). Twelve participants responded with a score of 10/10. The lowest score was a 5 from a single patient. <b>Conclusions:</b> Text messaging programs for gynecologic oncology patients are feasible in providing efficient postoperative care and are satisfactory to patients. Further study is needed to determine the safety and scalability of automated patient evaluation text messaging platforms.

Audit of Postoperative Readmissions and Patient Messages following Endoscopic Transnasal Transsphenoidal Surgery.

Objectives The aim of this study was to identify the reasons for patient messages, phone calls, and emergency department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery. Design This is a retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020 and August 2021. Patient, tumor, and surgical characteristics were collected, along with postoperative, postdischarge, and readmission information. Regression analyses were performed to investigate risk factors associated with postdischarge phone calls, messages, ED visits, and readmissions. Main Outcome Measures The main outcomes were the number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient's discharge instructions. Results A total of 98 patients underwent eTNTS during the study period. The median length of hospital stay was 2 days (interquartile range [IQR]: 1-4 days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9 days after discharge (IQR: 7-10 days). Within that time, 54% of patients made at least one phone call or sent at least electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, and symptom and medication questions. Conclusion Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.

Abstract 34: A Stroke Transition Of Care Intervention With Stroke Nurse Navigator And Early Stroke Clinic Follow-up Reduces Readmissions For Stroke At 12 Months

Introduction: Stroke is a leading cause of disability in the United States, and one in four occur in people who have already had a stroke. Preventable hospital readmissions contribute to the high medical costs of stroke. Transition of care programs have been successful in reducing hospital readmissions in other diseases, but the data on such programs for stroke is mixed. A transition of care program was implemented at a large urban stroke center, utilizing interventions shown to be effective in the literature, with the goal of reducing recurrent strokes and hospital readmissions. Methods: The transition of care program consisted of: two Stroke Nurse Navigators, personalized stroke education in the hospital, two-day phone call reinforcing education and reviewing medications, early follow-up within 7-10 business days with a Stroke Neurologist, and further education on personalized risk factors in the clinic. Baseline data from the year prior to intervention, and each quarter of the three-year project period were obtained on the following measures: Rate of recurrent stroke admissions within one year, all-cause readmission within one year, all-cause readmission within 30 days, patient scheduled for initial follow-up within 7-10 days, compliance with follow up in the stroke clinic, and percent of patients receiving two-day post discharge phone call. Discharge data were reviewed on 949 patients in 2016 (year 0) and on 2,328 patients in the three-year project period (starting in July 2017). Results: The rate of readmission for stroke was 8.5%, 9.0%, 6.6%, and 4.2% for year 0, 1, 2, and 3, respectively. This represents a reduction of 50% from the year prior to the intervention to year 3 of the grant. All-cause readmission remained stable, at 38.9%, 42.6%, 36.6%, and 37.4% for year 0, 1, 2, and 3 respectively. An improvement was seen in process measures: patients scheduled for early follow up in the stroke clinic, adherence to follow-up, and two-day post-discharge phone calls. Conclusions: In conclusion, the transition of care intervention led to a reduction from baseline in readmissions for stroke within one year, but did not impact all cause readmission at one year or 30 days. This is a meaningful outcome for those who have suffered strokes. This program can serve as a model.

Heart Failure Caregiver Burden and Outcomes: A Systematic Review.

Introduction/Objective:This review aimed to summarize articles describing caregiver burden and the relationship between health outcomes as well as describing interventions focusing on this population.Methods:The review used the PRISMA statement and Whittemore and Knafl guidelines. The search engines Scopus, PubMed, Ovid (PsycINFO), and CINAHL were searched for articles published in English.Results:This review included 30 studies that met the criteria. Physical, psychological, and social factors were associated with HF caregiver burden. HF caregiver interventions included health education, post-discharge home visits, phone calls, counseling, and support groups that demonstrated some potential to reduce the caregivers’ burden.Discussion:Healthcare provider team should screen for caregiver burden and promote healthy behaviors, and strategies to improve quality of life. Further studies should include caregivers as care team members and embed social networking in the interventions for reducing HF caregiver burden. The caregivers’ burden could influence the poor outcomes of care, including physical, psychological, societal, and functional dimensions. Future interventions should develop to alleviate HF caregiver burden.

Victims of Violence and Post-Discharge Adverse Events: A Prospective Modified Trauma Quality Improvement Program (TQIP) Study.

IntroductionTrauma patients frequently return to an emergency department (ED) soon after discharge; often for non-urgent reasons. Social factors contribute to higher ED usage. At present, there is no standardized system for reporting of ED visits and readmissions among trauma care. We hypothesized that victims of violent crime suffer from many early post-discharge adverse events that has not been captured by current methods.MethodsWe prospectively consented and enrolled injured patients from January 1st, 2019 to December 31st, 2019. We documented 30-day post-discharge events using post-discharge phone calls and detailed chart abstraction. Patients were categorized as victims of violence (VV) or unintentional traumatic injury (UT).ResultsDuring the study period, 444 patients were enrolled. Fifty-one (11.5%) were victims of violence and 393 (88.5%) experienced unintentional injuries. The VV patients were younger (40.10 vs 60.36; p<0.0001), and more predominantly male (92.16% vs 57.51%; p<0.0001). Total injury severity score (ISS), critical care length of stay (LOS), and total LOS were similar. VV patients were more likely discharged home (70.59% vs 55.47%; p=0.0403). They were significantly more likely to return to an emergency department (47.06% vs 23.16%; p<0.0005) and had more total number of ED visits per patient. Readmission rates, however, were not different (21.57% vs 16.28%; p=NS). The VV patients more frequently were underinsured (72.5%, vs 20.6%, p<0.005).DiscussionVictims of violence presented to the ED significantly more often, despite similar injury scores, LOS, and being of younger age. Of these patients, only 26.2% of ED presentations resulted in readmission, suggesting the majority of patient complaints may have been able to be managed in an office-based setting. VV had significantly more underinsured or subsidized patients. Victims of violence are vulnerable and may benefit from more resources provided in the early post-discharge period.

The effectiveness of post-discharge navigation added to an inpatient addiction consultation for patients with substance use disorder; a randomized controlled trial

Background: It is unknown whether post-discharge navigation enhances the impact of hospital-initiated addiction care. This study tested the incremental benefit of telephonic linkage to a post-discharge navigator for patients who received an addiction consultation during hospitalization. Methods: A two-arm, randomized controlled trial of 395 hospitalized adults with substance use disorder who received an addiction consultation. The intervention group received post-discharge phone calls from a navigator to review the recommended treatment plan and address barriers to engagement on days 3, 7, 14, and 21. The primary outcome was days of alcohol or drug use in the past 30 assessed by Timeline Follow-back at 1 month. Results: Follow-up assessment completion rates were 46% at 1 month, and 41%, at 2 months. At baseline, intervention and control groups did not differ in substance use patterns; 45% reported primary alcohol use, 43% drugs, and 12% both. Heroin was the most common drug. At baseline, mean days of past 30-day alcohol or drug use were 13.6 in the intervention and 14.9 in the control group. The median number of navigation calls completed was 3 out of 4. At 1 month, both groups reported less use (decrease of 4.8 in intervention vs. 4.2 days in control group, p = 0.49). There were no differences between groups at 2 months. Compared to controls, participants who received all four calls had a greater decrease in use with a mean 8.6 days decrease from baseline (difference of 4.4 days, p = 0.0009). Conclusion: Post-discharge telephonic patient navigation did not further improve substance use outcomes following addiction consultation.

Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses\u2019 and patients\u2019 perspectives

BackgroundAfter hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients’ post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers.MethodsGuided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model.ResultsParticipants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI).ConclusionsStrategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.

One Call Away: Addressing a Safety Gap for Urgent Issues Post Discharge.

The transition period from hospitalization to outpatient care can be high risk for pediatric patients. Our aim was to profile the use of a "safety net" for families through provision of specific inpatient provider contact information for urgent issues post discharge. In this prospective study, we implemented an updated after-visit summary that directed families to call the hospital operator and specifically ask for the pediatric hospital medicine attending on call if they were unable to reach their primary care provider (PCP) with an urgent postdischarge concern. Education for nursing staff, operators, and pediatric hospital medicine providers was completed, and contact information was automatically populated into the after-visit summary. Information collected included the number of calls, the topic, time spent, whether the family contacted the PCP first, and the time of day. Descriptive statistics and Fisher's exact test were used to summarize findings. Over a 13-month period, of 5145 discharges, there were 47 postdischarge phone calls, which averaged to 3.6 calls per month. The average length of time spent on a call was 21 minutes. For 30% of calls, families had tried contacting their PCPs first, and 55% of calls occurred at night. Topics of calls included requesting advice about symptoms, time line for reevaluation, and assistance with medications. This safety net provided families with real-time problem-solving for an urgent need post discharge, which included triaging patient symptoms at home, counseling on medication questions, information about the time line of illness recovery, and provision of additional resources.

Implementation of an enhanced discharge teaching protocol to reduce 30-day hospital readmissions in adults diagnosed with Sickle Cell Disease

Background and objectives: Sickle Cell Disease is a painful genetic disorder characterized by abnormal hemoglobin that affects 1-in-365 African American births. Individuals with Sickle Cell Disease often experience frequent hospitalizations, resulting in 30-day readmission rates 2.5 times higher than those without Sickle Cell Disease. Discharge education programs have shown to improve 30-day readmissions and improve health outcomes.Methods: This advanced practice nurse-led initiative incorporated components of the Re-Engineered Discharge (Project RED) protocol, which included patient and medication education, specific discharge teaching, and post-discharge follow-up phone calls over a 12-week period. A pre/posttest design was used to evaluate 30-day readmission. Analyses included descriptive statistics and Fisher’s exact test.Results: Of the (N = 10) participants, eight (80%) were female, with a mean age of 31.08 (± 4.33) and all were African Americans. Although not statistically significant, there was a 48% reduction in 30-day readmissions rates between the pre/post intervention periods.Conclusions: The utilization of an enhanced discharge teaching protocol is a practical solution to increase patients’ readiness for discharge and to reduce 30-day readmission rates. Project RED discharge teaching protocol is an effective strategy for nurses to employ to improve patient outcomes and quality of care for persons with Sickle Cell Disease.

Increasing Parent Satisfaction With Discharge Planning: An Improvement Project Using Technology in a Level 3 NICU.

Background:Neonatal intensive care unit (NICU) families are often overwhelmed by the discharge process. Their anxiety can inhibit learning and contribute to poor infant outcomes and increased healthcare utilization after discharge. Quality of the discharge teaching is the strongest predictor of discharge readiness, so NICUs must develop excellent discharge preparation programs.Purpose:This improvement project enhances NICU discharge preparedness by providing consistent, early discharge teaching using technology as a supplemental resource and raises parental satisfaction with the process.Methods:Neonatal intensive care unit staff and former NICU parents developed a task force to create technology-based discharge education content. The content was originally uploaded to an e-book and later transferred to the electronic health record inpatient portal. Families were able to view discharge teaching content at their own convenience and pace and review topics as needed with the NICU staff. Postdischarge follow-up phone calls provided insight into parental reaction to the new education format.Results:Parent satisfaction top-box scores, reflecting the highest rating in the “Prepared for Discharge” category of the patient satisfaction survey, improved from a baseline of 47% in 2017 to 70% in 2019. Overwhelmingly, 92% of families highly rated the tablet-based discharge teaching during postdischarge phone calls.Implications for Practice:A comprehensive, consistent, and early discharge program using technology can lead to more effective and efficient NICU discharge education and improved parent satisfaction.Implications for Research:Further studies are needed to generalize hospital-based inpatient portal teaching as an additional resource for parental education in the NICU.

The Impact of Telephonic Follow-Up Within 2 Business Days Postdischarge on 30-Day Readmissions for Patients With Heart Failure.

Heart failure (HF) is a chronic condition associated with high rates of hospital readmissions. The prevalence and costs of HF are expected to rise dramatically by 2030 (Heidenreich,et al., 2013). A 24-month, retrospective study was conducted using electronic medical record (EMR) chart review, seeking to identify if postdischarge follow-up phone calls decreased 30-day readmissions in individuals with HF. The study included 705 adult participants who were admitted to the hospital for HF. Some received a postdischarge call within 2 business days of discharge, and some did not. Participants who received the postdischarge call were less likely to be readmitted (20.1%) than participants who did not receive a postdischarge call (28.8%; p = .007). Participants who received the postdischarge call were more likely to have a follow-up visit within 14 days (70.1%) than participants who did not receive a postdischarge call (30.2%; p < .001). The findings from this study may help to drive future transitional care strategies for individuals diagnosed with HF. Nurse-led transitional care interventions offer potential solutions to ensure safe, effective hospital discharges.

The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial.

Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission. To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events. Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO). Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit. The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission. Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates. A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.