EXECUTIVE SUMMARY

Readmissions have dropped and patient satisfaction has increased among patients at UAB Medicine who receive interactive post-discharge follow-up calls.

• Patients answer a series of questions about how they are feeling, their understanding of their treatment plan, and their adherence to the plan, along with education about symptoms and signs of problems.

• The number and frequency of the calls depend on the patient’s diagnosis.

• Nurses in the call center are notified if answers indicate a patient needs intervention, and they connect the patient with the clinic team.


Readmissions have dropped and patient satisfaction has increased among patients at University of Alabama at Birmingham (UAB) Medicine who agree to receive interactive post-discharge phone calls.

When participants in the program are readmitted, their stays are shorter than other patients with the same condition, says JoAnn Clough, RN, MAON, ACM, transitional care coordinator, care transitions for UAB Medicine.

Patients who participate report a higher level of patient satisfaction with discharge teaching and care transitions than those who are not in the program, Clough adds.

UAB Medicine includes the School of Medicine and the UAB Health System, with six hospitals and 2,300 beds. UAB Hospital is the third-largest public hospital in the country.

The organization began the interactive calls in the spring of 2014 after partnering with a patient engagement technology company to develop disease-specific questions to ensure that patients understand and are following their treatment plan.

“Technology has enriched our level of engagement with our patients and has made our process more efficient. The technology system makes the initial calls and collects information from the patients, allowing the nurses at UAB to call only patients who indicate they have an issue,” Clough says.

Informing patients about the follow-up phone calls is part of the discharge education process, Clough says. “The inpatient case managers tell patients to expect the calls and tell them it is important to participate because the UAB nurses will be following them to make sure they are doing well,” she adds. About 80% of patients participate.

All patients who agree to participate receive an automated phone call the day after discharge and are asked to answer a series of questions including how they feel, if they have a follow-up appointment, transportation, and if they filled their prescriptions. The first call also includes education on what signs and symptoms indicate patients should call their doctor or go to the ED.

“The calls teach patients about their condition and how to manage it, and supplement the discharge teaching. They are designed to coach the patients so they learn what to watch for and what action to take,” Clough says.

Patients with certain conditions receive additional questions specific to their condition. Follow-up calls are made at intervals that vary according to the condition. For example, heart failure patients receive 45 calls over 45 days, and pneumonia patients are called 15 times over 30 days.

The software automatically identifies problem areas based on the patients’ answers, and alerts the nurses at a UAB call center. For instance, heart failure patients are flagged if they report gaining more than three pounds in a day or five in a week, she says.

The call center nurses receive a daily report and follow up with the patients who need it. Information on patients whose answers indicate they have a problem are in red at the top of the page. “The nurses are generalists and work closely with the staff at the clinics. If there is an issue that requires a provider, they can send them a message asking for assistance,” she says.

The calls usually are placed at 10 a.m. If patients don’t answer, they get another call around 1 p.m. When the phone rings, the caller ID cites UAB Medicine as the source of the call. The first call typically takes about three minutes; the others less than two minutes.

Patients can opt out of the calls whenever they choose, but most continue participating, Clough says.

“Patients do appreciate the calls, and some ask to be re-enrolled when the program is over. Some patients call us if they know they aren’t going to be home to take the call,” she says.

The hospital also sends patients an email link to a multimedia education program that they can view at home at their convenience. The programs are interactive and use art, animation, and plain language to address multiple learning styles and health literacy, Clough says.

The UAB team also uses technology to educate patients before any procedure or when they have a new diagnosis, Clough adds.

Patients who are scheduled for diagnostic procedures also receive a link to a video that explains the procedure and what to expect during the recovery period. An automated process scans the data files, identifies patients scheduled for procedures in two weeks, and sends them the link. After the procedure, patients receive follow-up calls through the care transition technology.

“The technology extends the reach of clinicians past the four walls of the clinic or hospital. The messages and education delivered engage and empower patients to take a more active role in their care. We know we’re doing a better job of supporting and educating our patients now that we can reach out to them via technology, while they are in their home,” Clough says.