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It makes sense that patients might have a higher opinion of their experience in the ED if someone contacts them soon after discharge to see how they're doing. But there is new evidence that these post-visit contacts can deliver other important benefits as well, improving clinical outcomes in some cases and reducing 30-day post-discharge admissions.
What's more, some pioneering hospitals are finding more efficient ways to both carry out the contacts and maximize the information they receive from patients. Take, for example, the experience of Edward Hospital in Naperville, IL, a facility that has dutifully initiated post-ED visit contacts in one form or another for more than a decade.
Beginning in 2004, the hospital hired a dedicated clerk to initiate the callbacks, using automatic phone dialing software and prepared scripts. "I created a database, a very basic one, which pretty much would keep track of the patients the clerk needed to call," explains Tom Scaletta, MD, FAAEM, chairperson and medical director of Emergency Services at Edward Hospital and Health Services. "Then we came up with a set of questions so she would go through the list, gathering information, and whenever she encountered an issue, she would relay it to the appropriate person."
For instance, if the clerk uncovered a clinical issue, she would contact the charge nurse; in other cases, patients might just need help maneuvering through the health care system or getting a follow-up appointment, notes Scaletta. "She helped out, the patients really appreciated it, and I think it improved care as well," he says.
Administrators say the callbacks, which went to patients discharged from the hospital as well as the ED, helped the organization sustain healthy patient satisfaction scores in the 95%-99% range, according to Press Ganey surveys. However, having a dedicated person on hand to make the calls is expensive, so for the past several years Scaletta has been working with computer programmers to create alternative ways to interact with patients following their ED visit.
"What I have been working on is trying to see how many patients we could actually reach where they would fill out a self-assessment," explains Scaletta. And what he has found is that many patients actually prefer communicating via e-mail or text.
"They don't want the phone to ring and to go running for it. They would rather get an e-mail or a text message, and to reply to it when they are ready," he says. "I think sometimes you actually get more thoughtful responses too, because when the phone rings people may just say everything is fine or they may just unload and not give a very thoughtful response."
The hospital hasn't abandoned the manual callbacks, but the way the system works now, these calls are reserved for those patients who do not respond by e-mail or text message. "We are currently getting about a 30% rate of response by text message. It is actually outpacing e-mail right now," notes Scaletta.
Typically, patients will receive a text and/or e-mail one day following their discharge from the ED, explains Scaletta. The message contains five questions, beginning with a query about how they are feeling. Patients then indicate that they are better, the same, or worse than the day they presented to the ED. When patients indicate that they are worse, the system automatically sends a fax to the ED and an e-mail message to the medical director so that they stay aware of the problem, explains Scaletta. "[Emergency staff] might call and check on the patient, they might ask the patient to come back, or they might just ask him or her some questions," he says. "This is the most critical question."
The second question asks the patient whether he or she has any questions regarding home care, medications, or follow-up appointments. If the patient answers in the affirmative, then an e-mail is generated to a hospital case manager who will then follow up, says Scaletta.
Questions three and four ask the patient to rate the level of concern shown by the physician and the nurse who took care of him or her in the ED. The possible answers range from very high (5) to very low (1). "We can sort our physicians and nurses out every single month by who is doing a better job," explains Scaletta, noting that administrators then share the findings with clinicians.
The clinicians understand that the expectation is that at least half of their patients will rank them as showing a "very high" level of concern, observes Scaletta. "They know they might become an outlier if they are not trying harder so that really boosts patient satisfaction," he says. "If 75% of the time I can achieve a very high score there, that will differentiate me from a physician who is only getting 50% or 25%."
Conversely, when patients report a very low score for a clinician, the computerized system prompts them to explain what the problem was, and an e-mail message is automatically sent to the medical director or nurse director, adds Scaletta.
The fifth and final question on the self-assessment provides patients with an opportunity to report any other comments or concerns they may wish to share about their experience in the ED. "This is where we might find out that the room was dirty, it was too cold, or the patient was placed in the hallway," explains Scaletta. "Whatever the issue is, it creates an opportunity to address complaints."
When these types of issues are reported, the department involved is notified electronically, but the system also generates an apology to the patient. "This way the patient feels like he has a voice and has been heard, and that in itself — that complaint resolution module — also boosts satisfaction and improves loyalty," observes Scaletta. "You can take a negative to a positive when patients realize they are being listened to."
Some clinicians take low scores or reported complaints personally — especially when the criticism is undeserved, acknowledges Scaletta. "[A clinician] might have done everything perfectly, but even so, there is going to be a certain amount of [dissatisfaction] in any service industry," he says. "There are going to be your chronic complainers, where even though you have done a perfect job, they are going to complain, and that is what I call noise. Everyone gets a certain amount."
To cut down on this type of noise, administrators simply avoid asking some patients to rate their clinicians. For instance, the hospital reliably gets complaints from patients who are identified drug-seekers, observes Scaletta. "We don't send them a request to find out what they thought about the physician or the nurse because we know it is going to be noise," he says. "Every day is going to be the worst day of their life and the physician didn't give them narcotics because they were flagged."
Even with such noise, however, higher-performing clinicians tend to like the patient feedback, says Scaletta. "They know this is an important aspect of health care delivery because when you engage patients, they are more likely to listen to instructions and get better," he says.
The clinicians who are low performers can be coached or given tools to help them improve, notes Scaletta. However, if their scores remain on the low end, they might not be a good fit, he says.
Scaletta credits the post-ED visit contacts with fortifying the ED's high patient-satisfaction levels, but he also believes they have played a role in bringing down admissions from the ED. "There are patients who are clearly going to be admitted and there are patients who are clearly going to go home, but there are also some patients in the middle who some physicians might admit and some others might send home," he says. "There is no right answer, but with a system in place that can check on patients the next day, I think that moves the needle just a little bit so that some physicians might be more comfortable [sending some of their patients home]."
Scaletta acknowledges that working with computer programmers to build the electronic system was expensive, but he is hoping to eventually recoup those costs by making the system available to other hospitals. For the time being, however, Edward Hospital is serving as the first test hospital for the approach.
Another hospital reaping benefits from post-ED visit and post-admission contacts is Cheyenne Regional Medical Center (CRMC) in Cheyenne, WY. While the practice has clearly made a positive impact on patient satisfaction surveys, administrators say they have also helped to improve patient compliance with care instructions, and the approach has made a dent in preventable readmissions.
Cheryl Crumpton, MSN, RN, CEN, the orthopedic-neurosurgery service line coordinator, oversaw the roll-out of the patient callback program at CRMC, beginning in June of 2011. "Here at our facility we require the RNs to make the calls, so hopefully they're the people taking care of the patients and they already know a little bit about their instructions and can answer more medical or medication questions than other staff would be able to do," she explains.
The calls are scheduled to go to patients between 24 and 48 hours post-discharge so that their care instructions are still fresh in the minds, notes Crumpton. "Our goal is to call 100% of our ED patients," she says. "It has been shown that if you actually reach and talk to 50% of those patients, that is a very successful number to make a difference in care and clinical outcomes."
Every day, the charge nurse compiles a daily assignment sheet, dividing up the calls that need to be made among the nurses working in the ED that day. "We see about 120 patients per day, so one nurse can't possibly call all those patients, so we split it up so that each nurse has between 10 and 15 calls to make a day, and they can prioritize their day however they want to in order to get those calls accomplished."
Crumpton acknowledges that it took time for the nurses to get used to making the calls. At first, they were allowed to come into work a little early or to stay a while beyond their shifts to get the calls completed, but with time, the nurses have become more adept at working the calls into their regular hours. "Each call only takes three to five minutes on average, so they are able to complete their calls pretty quickly," she says. Also, on days when a nurse is falling behind on the calls or is experiencing a particularly busy day, the charge nurse will step in and make some of the calls.
During the calls, the nurses ask the same types of questions that Edward Hospital uses on its post-ED visit self-assessment forms. In this case, the nurses have a script to follow, and some of the calls are followed by a patient satisfaction survey, explains Crumpton.
Given that the callbacks are an added task for nurses in a very busy environment, ED administrators interested in adding this type of program should anticipate some staff resistance. "There is always a little bit of pushback, but typically once you identify a couple of quality issues that you have helped to resolve with the call-backs, and you present those to staff, they pretty quickly understand the reasons for why we do them," says Crumpton.
For example, nurses completing the callbacks have uncovered several instances in which patients were taking their medications at the wrong doses, and they've been able to intervene in cases in which patients were experiencing treatment complications. "We had one woman who was treated for a brown recluse spider bite, and when we did a callback on here, her arm had gotten increasingly worse and she had a big, tunneling wound," says Crumpton. "The emergency nurse was able to direct her to the nearest ED and literally saved the woman's arm," says Crumpton. "When you take these cases back to staff, you are able to impress upon them why the callbacks are so important and what their contributions are to identifying these types of things."
Each ED needs to document its own success stories because these will generate a lot of buy-in, adds Crumpton. Improvements on key metrics can win over staff as well. At Cheyenne Regional Medical Center, where the callbacks go to both inpatients who have been discharged and ED patients, patient satisfaction jumped by more than 30% in the first quarter of 2012, and the hospital also saw a reduction of 13.59% in 30-day readmission rates post-discharge over 12 months.
Even with this kind of success, though, Crumpton has found that it is important for administrators to continuously reinforce why the callbacks are important. She also observes that there should be some type of mechanism in place to document that the calls have been made, and what transpired during the calls. "The program we use is automated, so we are able to track when the patients were called, what their answers were, how many patients were called, and which nurses made the calls," she says.
For accountability purposes, it is also important for administrators to actually observe staff making the calls on occasion, advises Crumpton. "You want to make sure they are quality calls," she says. "Sometimes when you call a patient, he has some concerns. You have to be able to actually address those concerns and to be able to listen and do some service recovery right there."
For instance, if a patient had to wait a long time to be seen, or his experience with a member of the emergency staff was not optimal, the callback nurse needs to apologize and reassure the patient that his complaint has been heard and that the issue will be followed-up on, notes Crumpton.
Another important skill that can be invaluable to the callback nurses, says Crumpton, is the so-called "teach back" method, in which you essentially ask patients to recount their own care instructions in order to verify that they understand what they need to do in terms of taking their medicines correctly, changing their wound dressings, or when to follow-up with their physician, for example.
When patients have very detailed instructions upon discharge, the ED nurses actually encourage them to write down any questions or concerns that crop up so they can review these with the callback nurse when she gets in touch.
Crumpton has found that information gleaned from patients during the post-discharge phone calls can help clinicians improve their own processes. For example, nurses on the hospital's same-day surgery unit discovered during these calls that once patients got home following a surgical procedure, they often did not understand when to change a dressing on a wound or when it was important to call the physician, she explains. "As a result, they created these big, bright fluorescent yellow packets of wound care instructions," says Crumpton. "They changed their practice because the staff identified a problem and then they owned their solution."