Post Discharge Follow-up Through An Automated Phone Call Program In A Tertiary Pediatric Center: Reducing Preventable Readmissions Program Anu Asnani, MPH, Kathy Mullin, RN, Jeff Foti, MD
Introduction Project Summary In February 2018, a 407 bed pediatric hospital implemented an automated follow up phone call process for all patients discharged from a hospital stay. The immediate transition home after a hospital stay is a vulnerable period for pediatric patients and their families related to: • Communication gaps between patient and medical team • Misinterpretation of discharge instructions • Difficulty obtaining prescriptions • Lack of follow-up post discharge Gaps in any of these may contribute to hospital readmissions or Emergency Department (ED) visits and is considered patient harm. The overall purpose of this project was to assure families had knowledge of these key elements to manage the patients’ medical needs at home Prior Work Follow-up calls for specific cohorts within 72 hours of discharge. • Finding: 2.4x more likely to be readmitted without follow-up call PCP appointments for specific cohorts within 7 days of discharge Clinical reviews of all 0-14 day readmissions including family input Standardized risk assessment to identify patient risk of transition and readmission (adopted from PediBOOST) Visibility of risk scores in medical record Discharge bundles implemented: • Pharmacy interventions • Complex scheduling pre-discharge • Discharge readiness checklist
Methods
Figure 2 Patient Intervention Categorized By Issue
Figure 3 Comparison of 0-14 Day Readmit Rates
Automated follow-up phone call process for 97% of patient population: • English (89.3%) • Spanish (6.8%) • Vietnamese (0.5%) • Somali (0.5%) Three call attempts and one SMS attempt initiated within 16 hours of discharge Manual call process with interpreter for all other patients: Two call attempts by RN Four questions related to: *Discharge instructions *Obtaining prescriptions *Medication instructions *Follow-up assistance
Table 2 Outcomes (August 2018-February 2019) Outcomes Prevented
Option to escalate for assistance or clarification. Email alerts for escalated calls RN calls back within 24 hours of escalation RN implements care management strategies and escalates to providers as indicated (PCP or specialty) Documentation of interventions in clinical information system
Results 2/2018-2/2019 • 13,210 patients called • Call reach rate: 72% (Target: 70%) • Call completion rate: 65% • Patient intervention rate:13% (Target:<20%) • Average time to intervene: 5 hours (Target: 24 hours) Figure 1 Patients By Language Who Answered Any Question
Total
Abrupt discontinution of medication Adverse medication side effect unnoticed by family/clinic team MD/NP call to the family Medication error Missed clinic visit Non-adherence to treatment plan due to misunderstanding between care team and family Unnecessary ER visit
32 8
Outcomes Occurred
Total
5 26 41 33
32
Connected family to medical home/PCP to help with 55 ongoing management of condition Encouraged medication compliance 29 Improved family's ability to better manage home 71 care and treatment due to education/guidance Prompted modification to medical care plan 12 Prompted referral to specialist 8 Reconciled medication-related discrepancies 8 Scheduled necessary clinic visit 8 Sent to ED for assistance (necessary ED referral) 1 Outcomes adopted from Boston Children’s Care Coordination Measurement tool
Caregiver efficacy and satisfaction for escalated calls were evaluated for a four month period: • 45 of the 76 eligible patients were successfully contacted. • 64% felt more confident in being able to care for the patient after speaking to the nurse. • 76% felt the call response was timely. • 91% of caregivers responded “yes” when asked by the RN if the call was helpful.
Conclusions • Although hospital wide readmission rates have not shown a sustained reduction, value has been added through outcomes prevented/occurred • Families who completed escalated calls expressed benefit of clarification • Higher readmission rate for incomplete/unsuccessful calls
Next Steps • Potential expansion of call program to Emergency Department patients • Further investigation of “hang-ups” and “incomplete” categories with higher readmission rates through manual calls • Changing methodology to one call attempt and one SMS text • Deeper dive into escalated call population
Acknowledgements: Aaron McAdie, Data Scientist Susannah Marshall, RN Case Manager postersession.com