Critial Path Network

Nurse line checks up on patients after discharge

Referrals made for patients who need follow-up

When a case manager or social worker at Saint Luke’s Medical Center is concerned about a patient who is being discharged, he or she asks the RNs staffing the hospital’s Nurseline to make a follow up call after the patient gets home.

Since the program began in May 2004, more than 100 patients have been referred to the Nurseline for follow-up and only eight of these have been readmitted — none for anything connected with the original admission, says says Anita Messer, RN, MHSM, ACM, director of care integration for the Kansas City, MO, hospital.

The Nurseline originally was established so patients could call in with questions after they left the hospital. The program has been revised to include outbound calls for patients who are flagged by case managers or social workers for post-discharge telephone calls. The initiative is budget-neutral since the hospital already had the Nurseline in place.

"These are patients we’re concerned about after they leave the hospital. They aren’t sick enough for home health care, but the social worker or case manager has identified some issue about their safety. They may not understand their discharge instructions and may need more help with this after they get home," says Melissa K. Thomas, RN, MSN, CPHQ, clinical project manager.

The hospital has follow up for patients with some chronic diseases, such as congestive heart failure, but there are others who need assistance but don’t qualify for post-discharge services.

"One of the main goals of the program is to catch patients who in the past may have fallen through the cracks. These are other patients who are not sick enough to qualify for home health or other services but are at risk for having to be readmitted if they don’t make a doctor’s appointment or get their prescription filled," Thomas says.

The order in which the discharged patients are called is based on an acuity system.

If a nurse or case manager identifies a patient as high acuity, the process is followed to flag Nurseline, and the patient is called the day after discharge.

If patients are low acuity, the Nurseline nurse calls them a few days later to make sure they are taking their medication, that they’ve scheduled a follow-up appointment with their physician, and are experiencing no signs or symptoms that might indicate complications.

When a case manager or social worker identifies a patient who meets criteria, they put it in the chart. The information assistant (or unit secretary) flags the patient on the electronic medical record and faxes the discharge summary to the Nurseline. The fax includes information about the acuity level of the patient’s follow up needs, what follow-up should be done, what medications were prescribed, and what the discharge instructions are.

"This initiative allows us to follow our patients after discharge and gives the nurses, the case managers, and social workers peace of mind. We’ve been able to prevent complex medical problems from occurring and to ensure that the patients are doing everything they need to do to recover quickly," Messer says.

For instance, when the Nurseline nurse called a man who was recovering from cardiac surgery, he reported having chest pain, which he thought was normal. The nurse evaluated his pain, determined it wasn’t normal, and made an appointment with his physician, who adjusted the medication, potentially preventing a readmission down the road.

Another patient who had a surgical procedure reported running a fever several days after discharge. The Nurseline nurse got the woman an appointment with her physician immediately and it was determined that she had a postoperative infection.

If the Nurseline nurses feel it’s needed, they make an appointment for the patient to see their physician. In some cases, they call the physician and ask for a home health visit if the patient is homebound or doesn’t have transportation.

Patients who are designated high acuity may be those on multiple medications who seemed confused about which to take when. They may live alone in a rural area or be someone who has had frequent readmissions.

"This is a transitory town. We have a lot of seniors who don’t have family around. The nurse line gives us a checkpoint to make sure they’re safe and understand their discharge instructions," she says.