Follow-up calls help avoid readmissions

CMs identify problems and work to solve them

In an effort to improve transitions of care, the nurse care coordinators at Brigham and Women's Hospital in Boston make follow-up calls to patients who have been discharged, identify problems and solve them, and answer questions the patients may have about medication, symptoms, or their discharge plan.

"One of the biggest benefits of the follow-up monitoring program is preventing hospital readmissions and visits to the emergency room. By calling the patients shortly after they are discharged from the hospital, we can discover any potential complications and proactively address them. While we don't have statistical data, we do have a lot of anecdotal information that demonstrates we have been able to intervene and solve problems for the patients," says Christine Dutkiewicz, RN, MSN, CCM, care coordination nurse manager at the 777-bed hospital.

The hospital has an average of 53,693 discharges and 59,323 emergency department visits each year and had a 30-day readmission rate of 8.79% for medical-surgical patients in 2009.

The Massachusetts Department of Public Health requires hospitals to follow up on patients who are discharged with multiple services or otherwise complex post-hospital needs or lack an informal personal support system.

At Brigham and Women's, nurse care coordinators are assigned by service line and follow the patient throughout the hospital stay. The same care coordinator who made the discharge plan makes the follow-up calls within a day or two after the patient is discharged, Dutkiewicz says.

The nurse care coordinators call any patient who is discharged home with post-acute services, patients who will be home alone after a hospital discharge, first-time mothers discharged to home with their babies, families of babies who are discharged from the neonatal intensive care unit, and any patient the care coordinator is concerned about after discharge.

The nurse care coordinators use their clinical judgment in determining the timing of the call based on past service utilization, access to care, and medical and social complexities.

They also call patients who are discharged from medical oncology and bone marrow transplant and patients who are discharged from thoracic services. The cardiac surgery service handles its own follow-up calls using its own distinct database.

The nurse care coordinators access clinical and demographic information about patients through an ambulatory electronic record. Using a standard template, they ask a series of questions about the discharge process, the adequacy of home care services, family support, pain management, medication, activity restrictions, and follow-up appointments.

They enter the information from the call into a longitudinal database that is accessible by other providers in the Partners Health Care System, which includes Massachusetts General Hospital, Brigham and Women's Hospital, three community hospitals, two long-term acute care hospitals, two rehabilitation hospitals, four skilled nursing facilities, a home care agency, a hospice, and more than 1,000 primary care physicians who practice throughout the state.

The nurse care coordinators use a follow-up monitoring template that includes the reason for admission, information about how the patient is feeling, pain management, medications, wound/ incisions, activities, home care visits, follow-up care, nurse care coordinator follow-up and referrals, and questions or concerns.

Each section has a drop-down menu that includes a series of questions in which the nurse care coordinators enter details about each patient response.

For instance, within the pain management section, the questions include: Is the patient feeling any pain or discomfort? How is the pain on a scale of 1 to 5? Does the pain medication help? Is the level of pain acceptable to the patient?

There is a list of types of medication (antibiotics, steroids, diuretics, etc.) and a list of types of questions (dose, frequency, side effects, duration, etc.) that the nurse care coordinators can record electronically using a check-off or point-and-click method.

Automated e-mails

The system automatically formats an e-mail that the nurse care coordinator can send to the primary care physician, home health nurse, or other providers if they have concerns about the patient. The e-mail includes the reason the care coordinator is asking for the follow-up and all the information gathered during the call.

When the nurse care coordinators uncover problems that might have occurred during the hospital stay, they send a report to the appropriate department leaders of individuals within the hospital, Dutkiewicz says.

"This is important information to share within the hospital to drive improvement activities," she adds.

Originally, the care coordinators documented their follow-up calls using a database that was accessible only to the care coordination department employees. The department has moved to an integrated system to enhance patient transitions, quality, and access, Dutkiewicz says.

The nurse care coordinators print a daily report of patients who were discharged the day before and use that to set up their call schedule. They start calling in the morning, make two attempts to reach the patient, and leave a message asking the patient to call back if the calls are unanswered.

The care coordinators always instruct the patient to call with any questions or concerns but it doesn't always happen, she says.

"Using this system, we take a proactive approach to identifying any questions and problems the patients are having and solving them before the patients are back in the hospital or the emergency room," Dutkiewicz says.

The majority of questions patients have concern medication or symptoms after surgery.

"Often, patients don't understand their discharge instructions. The entire episode of care, including discharge, may be overwhelming. Patients may not feel comfortable calling their doctor's office if they have questions or concerns. They wait for the symptoms to exacerbate before calling," Dutkiewicz adds.

The nurse care coordinators sometimes find that patients haven't filled their prescriptions due to costs or previously unknown preapproval requirements. Other times, the durable medical equipment hasn't arrived or the home health agency hasn't scheduled a visit.

"When we identify these problems, we work to solve them. We've even called 911 for patients when we were concerned about the acute nature of their reported symptoms," she says.

The care coordinators talk to the spouse or caregiver if the patient is unable to come to the telephone. If the patient is sent home with hospice care, they call hospice first, and then call the patient and family.

The follow-up calls help other providers in the Partners network coordinate care for the patients after they are discharged from the hospital, Dutkiewicz says.

For instance, if a patient comes into a community hospital's emergency department, staff can access the record and see the patient history and the care coordinator's report after the patient was discharged.

"Many changes need to happen in health care to improve patient outcomes. With public reporting of quality outcomes, payment, and health care reform, there is an additional incentive to conduct integrated follow-up monitoring of patients after they are discharged from the hospital," she adds.

(For more information, contact: Christine Dutkiewicz, RN, MSN, CCM, care coordination nurse manager, Brigham and Women's Hospital, e-mail: