Discharge phone calls play a significant role in decreasing unnecessary hospital readmissions not only in practice but also in identifying where workflow and culture changes are warranted.
Standardizing your discharge phone call operations by utilizing a centralized calling resource and electronic documentation not only makes your calls more productive and efficient but allows for trend analysis of the data collected.
Here are some examples of noticeable trends in discharge call data and how each can be addressed to fully optimize a readmissions reduction program.
Medication Delivery and Understanding
Trend: A high percentage of patients experience delays in getting medications within 48 hours of discharge.
Resolution: Implement a meds to beds program to ensure patients have all their medications on first does when they are home. Additionally, delivery of medications to the home can make a significant impact in ensuring doses are not missed. Engaging community pharmacies is a key to this initiative. The community pharmacists as well as facility pharmacist’s providing education improves medication adherence.
Understanding Disease Process
Trend: Low health literacy among patients and caregivers or lack of retention of the discharge instructions.
Resolution: Incorporating clinical teach back and other patient and family caregiver education programs that make patients aware of the most important signs and symptoms to recognize and what to do about them. Presenting the information in digestible bites is important as a full disease education can be overwhelming and confusing at this point in the treatment process.
Trend: A high percentage of patients not enrolled in existing intervention programs like Meds to Beds or agreeing to home health nurse.
Resolution: When new programs are implemented work flow changes are needed to ensure effectiveness. Engagement of hospitalist and unit nurses is a key component to achieving overall program performance.
Disease Specific Interventions
Trend: Increased readmissions to a specific DRG.
Resolution: Engage specialists as part of readmissions reductions efforts. For example, respiratory therapists and nutritionists can play a vital role in achieving successful outcomes for some patients. Engaging them in the committee tasked with decreasing total spend is essential. Disease specific physician clinics can improve continued quality
Emergency Room Physician Engagement
Trend: Patients returning to the emergency department are readmitted to frequently.
Resolution: Including the emergency department physicians in readmission reduction efforts helps close the loop on a thorough discharge process. Emergency departments are pressured with through put numbers therefore engaging them with the competing priority of reducing admissions and readmissions is important. Additionally, engagement of hospitalist physicians is key to overall success.
There are a few examples of how a well-structured and automated discharge phone calling program can assist with patients transition to the home but also can also provide the analytics needed to help management pinpoint new initiatives or culture and work flow changes can have the broadest impact on reducing readmissions.