When nurses call patients after discharge to make sure they understand and have followed through with medication, appointments and therapies, many hospitals across the country are discovering that readmission rates drop and patient satisfaction rises.
The findings echo a 2009 national survey by Boston University Medical Center published in the Annals of Internal Medicine and funded by the Agency for Healthcare Research and Quality. It found patients who clearly understand their care needs after discharge are 30% less likely to be readmitted or visit the ED than patients who dont understand.
Now the Centers for Medicare & Medicaid Services uses the Re-Engineered Discharge Toolkit developed by researchers to help hospitals prevent readmissions.
Nurses at NYU Langone Medical Center in Manhattan have made calls to patients returning home since 2010. “Readmissions have decreased and patient satisfaction has increased — in direct correlation to the time we started the program,” said Regina Presa, RN, BSN, MBA, director of care management for the department of nursing.
Presa said five nurses with BSN degrees, some with special certifications, were hired to ask a list of questions during the calls, which take about 13 minutes each.
Heart failure patients targeted
In January, NYU Langone started a separate call-back program specifically for heart failure patients because they are among the most medically complex patients and have a high rate of readmission. Nationally, more than one in four returns to the hospital within 30 days.
Ana Mola, RN, MA, ANP, director of care transitions and population health management at NYU Langone, said nurses there call heart failure patients within 72 hours of discharge, making sure they have scheduled their next physician follow-up and assisting with that if needed.
Then, a social worker calls within seven days to see whether there are any psychosocial issues to address and whether patients are getting the home care and medications they need.
“Within that home-care population, we stratify them into high risk, moderate risk and low risk,” Mola said. “If they are high risk, they will also have a nurse practitioner with a specialty in heart failure either calling them or visiting their home within 72 hours of discharge.”
Mola said the calls have helped reduce the readmission rate for heart failure from percentages in the low 20s last year to 16% as of the first quarter this year. “Thats better than the national average, and its trending down,” she said.
Because one of the biggest problems is medication reconciliation, nurses also reach out to patients providers in the community to see whether their physicians have questions as well.
South Nassau Communities Hospital, Baldwin, N.Y., also targets heart failure patients for calls after discharge.
Peter Fromm, RN, MPH, FAHA, FACHE, an administrator at SNCHs cardiovascular center, led a team that developed and implemented a call-back program for heart failure patients.
Calls are made by two nurses with specific heart failure expertise. They help bridge the gap when information gets lost in the flurry of instructions at discharge.
“Its a very stressful time,” Fromm said. “Also, these patients tend to be older. Heart failure is the No. 1 cause of admission to the hospital in patients over 65 and so these patients may require reinforcement of the information that was given to them. Its difficult for any patient to receive this information all at once.”
Even with a fairly high volume of heart failure patients, he said, the calls do not require additional staff. The calls were added to the duties of nurses who work in cardiac imaging.
The national average rate of readmission within 30 days for heart failure patients is 25.9%, according to CMS. “That was our rate just over a year ago,” Fromm said.
Since the program started, that rate was cut to 13%, he said.
Nurses making the calls start with a script, but go off the script when patients have questions.
The questions have helped refine care before patients leave the hospital. One of the things nurses discovered was that dietary instructions were confusing patients. Now, every patient sees a clinical dietitian before they leave the hospital, Fromm said.
Many patients might think eating soup, for instance, is a healthy choice. But they might not know that soup can have a high sodium content, so they need to find low-sodium versions.
The calls usually are appreciated, Fromm said. But even when they arent, they get results.
Fromm told the story of a woman who asked, “If I go to the doctor, will you stop calling me?” The nurse said, “Absolutely.” The patient went to the physician, was treated and didnt have to go back into the hospital.
At Sound Shore Medical Center in New Rochelle, N.Y., discharge calls are particularly important in the Joint Solutions hip and knee replacement department.
Nurses learn the results of discharge calls in monthly interdisciplinary meetings with physicians, pharmacists, therapists and physician assistants, and also in nursing staff meetings twice a month.
Learning what information patients say they are missing after discharge has helped nurses refine their instructions before patients leave the hospital, said nurse practitioner Peggy Coll, RN, who is nurse manager of the orthopedic unit and coordinator of the Joint Solutions department.
The discharge call program has been in operation for about two years, Coll said. It was implemented without added expense because Coll makes most of the calls herself — usually between 25 and 35 a month. A retired volunteer nurse also makes calls, which take about 15 to 20 minutes each, Coll said. If the volunteer nurse makes a call and a patient has a clinical issue, she will present it to the charge nurse, who then will follow up with the patient.
Coll said the calls help patients in two main areas: medication adherence and reinforcing the importance of anticoagulant therapy.
Patient response has been very positive, Coll said.
“They like the fact that you reached out to them, that you care enough to give them a call,” she said. “It has prompted some of them to put their thoughts in a thank you note. When you hear the appreciation from the patient, it makes the time worth it.”
— Marcia Frellick is a freelance writer.
LEARN MORE about the RED Toolkit online at AHRQ.gov/ Professionals/Systems/Hospital/Toolkit/REDTool5.html.