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Follow-up program shows positive outcomes
Readmission rates lowered
Hospitals often have nurses call patients after discharge in hopes of improving their satisfaction ratings. A new study shows that there are a couple of very good reasons to provide these calls, but a boost in reported patient satisfaction is not one of them.
"A five-minute telephone call isn't going to change your perceptions about what happened while you were in the hospital," says John David D'Amore, MS, a researcher with the University of Texas School of Biomedical Informatics at Houston.
But here's what the five-minute nursing call did change:
Readmission rates were lower for patients who received the telephone follow-up.
Patient satisfaction survey return rates were higher for people who received the follow-up call.
The nursing calls originally were initiated years ago by Memorial Hermann Healthcare System of Houston as an informal process to check with patients post-discharge, says Helen Powers, BSN, MBA, assistant executive at Memorial Hermann Healthcare System, a multihospital system in Southeast Texas.
"Now that there are lots of financial incentives or penalties for readmission that are imposed by the federal government, then the follow-up calls are something that has to have an infrastructure," Powers says.
Memorial Hermann Healthcare uses an electronic post-discharge callback system for making and tracking the nursing calls.
"We wanted a system that would document and make sure we made all the calls," says John Murray, MBA, senior business analyst with Memorial Hermann Healthcare System.
Clinicians in nursing departments make the calls, which include six standard questions, including questions about pain, discharge instructions, prescriptions, follow-up appointments with physicians, and an inquiry about recognizing any physicians or staff for a job well done.1
The last question has proved very useful for providing feedback to staff and departments, Murray notes.
"We're collecting 1,600 compliments per month through the system and 60 complaints, which are opportunities for improvement," he says. "We send emails to patient relations staff if there are concerns, and we pass on the compliments to department managers."
This particular question on the post-discharge callbacks was one that many hospital employees perceived would result in larger numbers of complaints, he says.
"Instead, we have 25 times as many compliments as complaints," Murray says.
The electronic system automatically lists patients who have been discharged home from each unit, and someone on that unit usually a nurse or volunteer makes the call, Powers says.
"This could be a layperson making the calls because it's pretty well scripted," she adds. "We try to ascertain the patient's level of comfort with their discharge information and identify any issues they need to address."
One key factor involves timing.
"We try to call the day after discharge or within that four-day window," Murray says. "We think our biggest opportunities are within those first four days after they go home."
From 2008 to 2009, 10 nursing units in the hospital, representing nearly 14,000 patient discharges, were examined. More than 10,500 received the post-discharge calls, and a little less than half were reached by the caller. Each nursing department spent about one to two hours per week conducting the follow-up calls.1
D'Amore and co-investigators conducted an observational study of data from an eight-month period to see what the outcomes were for the calls.
One outcome involved the patient satisfaction surveys, which were the Hospital Consumer Assessment of Healthcare Providers and Systems survey: "Patients always received the phone call before they received the survey in the mail, so did these calls influence patient satisfaction?" D'Amore says.
The answer was that the calls did not make any difference in survey results.
For the next outcome measure, investigators collapsed databases and connected data, including administrative data, readmission information, and demographic data that was de-identified, he says.
They examined the differences between patients who received the post-discharge callback and those who didn't and found that 22.4% of patients who received the calls mailed in the survey, versus 15% of patients who did not receive the calls.1
For 30-day readmission rates, the telephone follow-up combined with a scheduled physician appointment predicted a lower readmission rate. For those patients, the rate was 9.5% versus 10.8% for patients who did not receive the nursing call.1
The readmission results were positive enough to warrant a continuation of the callback system, Powers says.
"If you consider readmission after an acute episode is a failure in the system, then what you're doing is improving quality of care for patients by providing the calls," she says. "The readmissions could be caused by the patient not knowing what they were supposed to do post-discharge or because they're not taking their medications correctly."
The study's most illuminating finding was that the callbacks were most effective when combined with patients scheduling an appointment with their community physician, she notes.
"A number of the people we're readmitting to the hospital are not following up with their physician," Powers says.
The study's positive findings have long-term implications for hospitals, D'Amore says.
"This was a very encouraging study," he adds. "And Memorial Hermann has continued to expand the system and do more things to connect care."
For instance, if a patient does not have a scheduled follow-up visit with a physician, then the hospital post-discharge caller can transfer the patient to a scheduling system which would assist the patient in making that appointment, D'Amore says.
Also, the study's findings suggest there is a positive relationship between having one hospital employee designated as responsible for making sure all discharged patients have appropriate follow-up care arrangements, Murray says.
"We can build relationships with primary care physicians in the hospital's area and channel more patients to physicians' practices by putting patients in touch with them," he explains. "We don't have data to analyze the impact of that, but our real goal is to make sure we can facilitate a primary care physician relationship before the patient leaves the hospital."
This type of continuity of care thinking and processes will lead the nation's health care system down the path of prospective management of care transitions and are much-needed, D'Amore says.
"It's creating a model where patients have to actively opt out," he adds. "The default position is they get appropriate care that is standard practice."
And it's good for hospital business: "We're not only doing this because it's the right thing to do, but CMS has identified this as a big cost driver in the health care arena and is issuing penalties in October 2012 for readmission rates above national average," Powers says.
1. D'Amore J, Murray J, Powers H, et al. Does telephone follow-up predict patient satisfaction and readmission? Pop Health Manag 2011;14:1-7.
John David D'Amore, MS, Researcher, University of Texas School of Biomedical Informatics, Houston, TX. Email: email@example.com.
John Murray, MBA, Senior Business Analyst, Memorial Hermann Healthcare System, Houston, TX. Email: firstname.lastname@example.org.
Helen Powers, BSN, MBA, Assistant Executive, Memorial Hermann Healthcare System, Houston, TX. Email: email@example.com.