Spotlight Case

1. Spotlight Case Postdischarge Follow-Up Phone Call

2. Source and Credits • This presentation is based on the March 2012AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Division of Hospital Medicine, University of California, San Francisco • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand why preventing readmissions through postdischargephone calls is important • Describe the evidence supporting postdischargephone calls • List important steps in implementing a postdischargephone call program • List common pitfalls when establishing a postdischargephone call program

4. Case: Postdischarge Phone Call (1) A 63-year-old woman with a history of COPD presented with several days of a productive cough, shortness of breath, and fever. Diagnosed with community-acquired pneumonia and admitted to the hospital, she was treated with ceftriaxone and doxycycline, intravenous fluids, and supportive care. The patient improved rapidly over 48 hours and was discharged home (she lived with her daughter and grandson) with a prescription for doxycycline (an oral antibiotic) to complete a 7-day course and guaifenesin for a persistent cough.

5. Case: Postdischarge Phone Call (2) Over a few days following discharge, the patient’s cough worsened and shortness of breath returned, despite the antibiotics. She called her primary physician to schedule an urgent appointment, but he was away and no appointments were available. She vaguely remembered being given a number at the hospital to call if she had any issues at home, but she could not find it in the stack of papers she received at discharge. As her symptoms worsened, she contemplated returning to the emergency department.

6. Case: Postdischarge Phone Call (3) That afternoon she received a call from the hospital. (All patients discharged from medicine service at this hospital are called by a nurse within 3 days.) The nurse learned about the worsening symptoms and contacted the discharging team. Concerned that the patient’s pneumonia was returning and she was failing the doxycycline treatment, the team contacted her local pharmacy and prescribed levofloxacin (a broader spectrum antibiotic). The patient’s daughter was able to get the prescription the same day and the patient began taking the levofloxacin.

7. Case: Postdischarge Phone Call (4) The nurse who had called previously called again 2 days later to check on the patient. With the change in antibiotics, the patient felt much better. She did not need to return to the hospital and was able to see her primary care doctor 2 weeks later. The discharging team was convinced that the follow-up phone call from the nurse had definitely prevented a return visit to the ED and potentially a readmission to the hospital.

8. Background: Transitions in Care • The period following hospitalization remains a particularly vulnerable time for patients • Multiple studies have shown that adverse events occur in approximately 1 in 5 patients • Readmission is common—nearly 20% of hospitalized older Medicare patients will be readmitted within 30 days See Notes for references.

9. Discharge Transition (1) • Hospital-based transitional care interventions aim to smooth the transition from inpatient to outpatient setting and (potentially) prevent unplanned readmissions

10. Discharge Transition (2) • Multiple strategies have been employed to avoid preventable adverse events after discharge and prevent rehospitalizations: • Patient engagement in discharge planning • Transition “coach” • Communication with outpatient providers • Timely follow-up appointments • Home visits • Postdischarge phone calls (as in this case) See Notes for references.

11. Discharge and Readmissions • Preventing readmissions is a growing area of focus • The new health care law has provisions focused on readmissions, including eventual financial penalties for hospitals with high readmission rates • Readmission rates are publicly reported through Medicare • Readmissions can negatively affect the patient, the family, and the health care system See Notes for references.

12. Postdischarge Phone Call in this Case • A nurse-initiated phone call using a focused script elicited the patient’s new symptoms • The nurse was able to reach the discharging team and with prompt action, likely a visit to the ED and a readmission were prevented

13. Postdischarge Phone Calls • Phone calls like this can identify key issues at discharge including: • Problems understanding discharge instructions • Obtaining outpatient appointments • Problems filling prescriptions • Other issues with medication management • New or worsening symptoms See Notes for references.

14. Contact clinical pharmacist Postdischarge Follow-Up Phone Call Algorithm Questions regarding medications or prescriptions Confirm prescription pick up Refer to electronic discharge summary Questions regarding follow up appointments, discharge instructions, or pending test results Nurse Initiated Follow-up Call Contact scheduler or hospitalist attending of the day Case manager / social worker documentation Questions regarding aftercare plan/ home services Contact case manager / social worker if necessary Emergency: call 911 Questions regarding symptoms Urgent: refer to urgent care or PCP Non-urgent: contact PCP and hospitalist attending of the day

15. Research on Postdischarge Phone Calls (1) • Studied as part of multi-modal interventions or as a standalone • Studies of phone calls as separate interventions are of poor methodological quality • Results have been mixed about the benefits of postdischarge phone calls See Notes for references.

16. Research on Postdischarge Phone Calls (2) • Calls may reduce readmissions in patients with CHF or reduce ED visits in other patient populations • While the supporting evidence is not robust, there are multiple possible benefits for these calls. Because of this, they are generally recommended to help in the transition from hospital to home See Notes for references.

17. Implementing a Postdischarge Call Program • Identify appropriate provider to make the calls • Create resource network for person making calls to facilitate care • Provide call-back number for patients if leaving a message • Develop standard script and formatted questions • Ensure provider making calls has access to electronic medical record and discharge summary • Track call outcomes to help provide feedback to inpatient and outpatient providers

18. Pitfalls in Postdischarge Calls • A calling provider who lacks adequate training or support may actually increase visits to the emergency department, potentially increasing readmissions • Continuity of care may suffer if primary physician is not contacted regarding postdischarge issues

19. Necessary Resources • Institutions need to consider the volume of patients and the estimated time per call • Studies show most calls take 10-20 minutes each • Calls may take more time if interventions are needed • Institutions may choose to focus on high-risk patients • Elderly, certain diagnoses, high-risk medications

20. Take-Home Points (1) • Transitional care interventions, such as postdischarge phone calls, can reduce adverse events and readmissions after discharge, which are costly to both patients and hospitals • Little solid evidence exists linking follow-up phone calls (as an isolated intervention) to reduced readmissions, but postdischarge phone calls have been a part of nearly every successful multi-modal transitions program

21. Take-Home Points (2) • An effective follow-up phone call program employs providers who can recognize postdischarge issues and utilizes a network of providers to intervene on behalf of the patient • A formal script to elicit questions/concerns, a method to document communication in the medical record, and a connection with primary care providers can improve success of the calls