Follow-up calls improve patients' health outcomes

Focus is on resolving psychosocial issues

Hospital social workers using telephone follow-up of at-risk patients have made a positive impact on patient care and satisfaction outcomes, a pilot program shows.

The enhanced discharge planning program was begun as a pilot project in 2007, says Gayle E. Shier, MSW, project coordinator of the older adults programs at Rush University Medical Center in Chicago.

The program is a collaboration between Rush University Medical Center's older adult programs and the case management department.

The pilot program results showed that its target population had some crucial care coordination needs.

"More than 50% of our pilot participants had some sort of ongoing need that took us more than one call to resolve," says Madeleine Rooney, MSW, medical center liaison for older adult programs at the Rush medical center.

The program began as a quality improvement project, but has evolved as hospital leaders learned more about this population and the impact of follow-up on their overall care and health, says Rooney, who has extensive experience in working with older adults and in hospital discharge planning.

The most common issues involved a need for follow-up on referred services, an adjustment to new illnesses or treatment, increasing dependency on others, and caregivers requiring emotional support, according to the pilot findings.

In June 2009, the hospital turned the program into a randomized, controlled study that will report Medicare data about rehospitalization rates for patients receiving the follow-up intervention vs. standard care, Shier says.

The results won't be published for a while, but so far researchers are seeing a good readmissions trend in the study, she says.

"Another thing we are seeing in the study is how we're having a positive impact on people making it to their medical appointments," Shier says. "People love this program and love that someone cares about them after they leave the hospital."

This bonding experience could be improving the hospital system's revenues by bringing back patients for outpatient care and enhancing the hospital's reputation, she adds.

The program was started as a collaboration for the purpose of promoting patient safety and quality of life and improving health outcomes. Also, its goals are to reduce unnecessary health care costs for older adults and creating a bridge between the hospital and the community.

"Our goal is to make sure the patient is stable at home and that the caregiver is supported," Shier says. "We make sure the appropriate services are started in the home, and we work to connect patients with their follow-up medical appointments."

Its discharge planning includes the development of discharge standards of care that ensure the medical team stays on track. And with social worker involvement, the program incorporates a psychosocial framework that includes finding community support for at-risk seniors.

Here's how the telephone follow-up program works:

1. At-risk patients are identified through an electronic database.

"We identify patients through an electronic report that stratifies their risk of rehospitalization," Shier says."We receive a verification that patients with our risk criteria have been discharged," she says.

The referral criteria was developed from a literature review and the pilot program's experience, as well as from case manager feedback.

"Patients are leaving the hospital sooner and sometimes with more acuity than they might have had historically," Rooney notes. "For seniors, in particular, they're more vulnerable to poor outcomes for different reasons, and those sometimes include cognitive and physical limitations, social isolation, and lack of financial resources."

It is these patients who need follow-up support the most, she adds.

Patients in the program must meet all of these referral criteria:

• The patient must be age 65 or more years.

• The patient speaks English.

• The patient is returning home after discharge.

• The patient has been prescribed seven or more medications.

• The patient does not have a primary diagnosis of a transplant.

They also must meet one additional criteria, including one of the following:

• The patient must live alone.

• The patient is without a source of emotional support.

• The patient is without a support system for care.

• The patient has a high falls risk.

• The patient is discharged with a service referral.

2. A discharge planning social worker assesses referred patients.

The program has three primary social workers, and their caseload is dependent on the hospital's census, although typically they'll have four new patients per day per clinician, Shier says.

"They also might have other cases from previous days," she adds.

Before calling patients, the social workers will review their patients' records and case management notes for any pertinent medical and psychosocial information.

They also do the following:

• Social workers investigate patients' previous hospitalizations.

• Social workers identify potential problem areas requiring in-depth assessments.

• Social workers generate a list of questions related to potential problems.

• Social workers obtain information about the patient's situation from other providers as necessary.

3. The social worker calls patients.

Social workers call patients within 24 to 48 hours post-discharge from the hospital, Shier says.

The call's purpose is to perform a basic biopsychosocial assessment and to stabilize the patient's post-discharge situation. Social workers also make certain the patient will be able to follow-up with medical providers and receive all of the community services he or she needs.

During the call, social workers ask patients some specific questions about the issues identified during the patient's risk assessment and chart review.

The calls often become a means for patients to receive psychosocial support.

"An interesting thing we've found is that some patients and their families are willing to share information with us that they might not be willing to share with their doctor or nurse," Rooney says.

"Sometimes, this is because of the questions we ask people," she explains. "We often ask caregivers how they're doing, and many will laugh and chuckle and say, 'No one asks me how I'm doing.'"

4. Develop appropriate interventions.

Once problems are identified, social workers seek a solution.

"We look at which interventions might be associated with those problem areas and which outcomes we'd anticipate or expect," Shier says.

"The point is for us to not be the ones who will do everything for patients, but to be the ones who have the capability to connect them with people who can do more," Shier says. "And we help people follow through with their care."

Interventions often include having social workers call the patient's primary care provider to let them know what the chief issues are and how these are being addressed.

A communication path is developed, and it works best when it goes in both directions, Rooney notes.

"It's not just having information that goes out of the health care system to the community; it's also having information that comes out of the community and back into the system," she says.


For more information, contact:

• Madeleine Rooney, MSW, Medical Center Liaison for Older Adult Programs, Rush University Medical Center, 710 S. Paulina St., Suite 427, Chicago, IL 60612-3814. Email:

• Gayle E. Shier, MSW, Project Coordinator, Older Adult Programs, Rush University Medical Center, 710 S. Paulina St., Suite 427, Chicago, IL 60612-3814. Telephone: (312) 942-8182. Email: