Reducing readmissions is top of mind for hospital leaders across the country as they face Medicare penalties for avoidable readmissions. To prevent readmissions and improve patients' health, IPC The Hospitalist Company designed a short-term program using a call center to transition patients from the hospital to home after discharge.
The numbers
From October 2010 through September 2011, the IPC Call Center tried to contact 350,000 patients with a 30 percent success rate. Of the patients who were successfully contacted, 24 percent needed an intervention. Twenty-seven percent of patients who required an intervention needed treatment for symptoms; 25 percent had access to care issues; 24 percent had medication issues; 12 percent had home health issues; and 12 percent had issues categorized as "other."
Overall, the program estimated it prevented 1,782 potentially avoidable readmissions. Now, the call center tries contacting approximately 40,000 patient-to-home discharges a month, with a capture rate of more than 40 percent.
Discharge notes guide questions
After a patient is discharged from the hospital to home, an IPC hospitalist at the hospital sends a discharge report to the IPC call center and the patient's primary care physician or specialist. The discharge report includes notes on the patient's condition and post-discharge instructions. Nurses at the call center use these discharge notes to tailor their questions to patients.
The call center nurses call patients between 48 to 72 hours post-discharge, and ask about symptoms, medication, home health services (if they were prescribed) and follow-up appointments. Using the discharge notes, nurses can ask about specific symptoms and medication. For example, for a patient with chronic obstructive pulmonary disease, a nurse would ask about the patient's breathing. For a patient who had deep venous thrombosis, the nurse would ask if the patient was able to pick up Coumadin, if that was the medication prescribed.
Resolving issues
If a patient has a serious medical need, the call center nurses contact the hospitalist and/or the primary care physician to provide what is needed. For example, in one case, a call center nurse found a patient with COPD was short of breath, and notified a hospitalist. The hospitalist contacted the patient and found the home health nurse had not come. The hospitalist called 911 for the patient, who was brought to the nearest hospital due to dangerously low oxygen levels. By contacting the patient within two to three days post-discharge, the nurse and hospitalist were able to intervene before the patient's condition became life-threatening.
Communication: Accuracy, timing, inclusiveness
Communication is the lynchpin of the post-discharge program. "We are based on communication," says Susana Ashton, RN, IPC Call Center director. "That's what makes the system work."
Kerry Weiner, MD, IPC chief clinical officer, also points to the universal importance of communication in transitioning patients to home. "No mater what transition strategy you have in any place in the country, it has to involve contacting and communicating with patients after discharge," he says.
Three critical elements of successful communication include accuracy, timing and inclusiveness.
Accuracy
Having accurate information is essential for communication among healthcare providers and between providers and patients. One challenge the call center faced was getting patients' correct phone numbers. The main reasons for not being able to reach roughly 70 percent of patients in the study from October 2010 through September 2011 were "no answer" and "a wrong or missing phone number."
By focusing more on getting accurate phone numbers, IPC was able to increase the percent of patients they contacted to more than 40 percent. The patient's phone number in electronic records or on admission forms may not be the best number to reach the patient. Providers can be proactive in obtaining correct phone numbers by asking the patient directly what the best number to contact him or her is. "The key is to really find out where the patient or patient's caretaker can be reached on the first call," Dr. Weiner says.
Timing
Contacting patients within the 48- to 72-hour period is critical for preventing readmissions. The call center typically does not call within the first 48 hours to give patients a chance to fill medications and make follow-up appointments. After 72 hours, it may be too late to prevent a readmission.
In order for the call center nurses to call patients between 48 and 72 hours after discharge, it is essential the hospitalists send their discharge notes within 48 hours after the patient's discharge. Hospitalists are reminded to send their discharge notes within this time period by physician group leaders at weekly meetings and by IPC, which tracks hospitalists' compliance, according to Irene Kuizon, DO, a hospitalist at Mercy Hospital in Miami. At IPC, the hospitalists' bonus opportunity is connected to the timely sending of their discharge notes.
Inclusiveness
Successful communication is also dependent on the inclusion of all stakeholders. The call center nurses, the hospitalists, primary care physicians and patients are all in contact to coordinate care post-discharge. The call center nurses also contact home health agencies and insurance companies when needed.
"We have to have all the parties taking care of the patient involved," Ms. Ashton says. "The more that we keep the parties updated on the discharge of the patient, the better chance this patient is going to have to [receive appropriate care] after discharge."
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| Susana Ashton |
The numbers
From October 2010 through September 2011, the IPC Call Center tried to contact 350,000 patients with a 30 percent success rate. Of the patients who were successfully contacted, 24 percent needed an intervention. Twenty-seven percent of patients who required an intervention needed treatment for symptoms; 25 percent had access to care issues; 24 percent had medication issues; 12 percent had home health issues; and 12 percent had issues categorized as "other."
Overall, the program estimated it prevented 1,782 potentially avoidable readmissions. Now, the call center tries contacting approximately 40,000 patient-to-home discharges a month, with a capture rate of more than 40 percent.
Discharge notes guide questions
After a patient is discharged from the hospital to home, an IPC hospitalist at the hospital sends a discharge report to the IPC call center and the patient's primary care physician or specialist. The discharge report includes notes on the patient's condition and post-discharge instructions. Nurses at the call center use these discharge notes to tailor their questions to patients.
The call center nurses call patients between 48 to 72 hours post-discharge, and ask about symptoms, medication, home health services (if they were prescribed) and follow-up appointments. Using the discharge notes, nurses can ask about specific symptoms and medication. For example, for a patient with chronic obstructive pulmonary disease, a nurse would ask about the patient's breathing. For a patient who had deep venous thrombosis, the nurse would ask if the patient was able to pick up Coumadin, if that was the medication prescribed.
Resolving issues
If a patient has a serious medical need, the call center nurses contact the hospitalist and/or the primary care physician to provide what is needed. For example, in one case, a call center nurse found a patient with COPD was short of breath, and notified a hospitalist. The hospitalist contacted the patient and found the home health nurse had not come. The hospitalist called 911 for the patient, who was brought to the nearest hospital due to dangerously low oxygen levels. By contacting the patient within two to three days post-discharge, the nurse and hospitalist were able to intervene before the patient's condition became life-threatening.
Communication: Accuracy, timing, inclusiveness
Communication is the lynchpin of the post-discharge program. "We are based on communication," says Susana Ashton, RN, IPC Call Center director. "That's what makes the system work."
Kerry Weiner, MD, IPC chief clinical officer, also points to the universal importance of communication in transitioning patients to home. "No mater what transition strategy you have in any place in the country, it has to involve contacting and communicating with patients after discharge," he says.
 |
| Dr. Irene Kuizon |
Three critical elements of successful communication include accuracy, timing and inclusiveness.
Accuracy
Having accurate information is essential for communication among healthcare providers and between providers and patients. One challenge the call center faced was getting patients' correct phone numbers. The main reasons for not being able to reach roughly 70 percent of patients in the study from October 2010 through September 2011 were "no answer" and "a wrong or missing phone number."
By focusing more on getting accurate phone numbers, IPC was able to increase the percent of patients they contacted to more than 40 percent. The patient's phone number in electronic records or on admission forms may not be the best number to reach the patient. Providers can be proactive in obtaining correct phone numbers by asking the patient directly what the best number to contact him or her is. "The key is to really find out where the patient or patient's caretaker can be reached on the first call," Dr. Weiner says.
 |
| Dr. Kerry Weiner |
Timing
Contacting patients within the 48- to 72-hour period is critical for preventing readmissions. The call center typically does not call within the first 48 hours to give patients a chance to fill medications and make follow-up appointments. After 72 hours, it may be too late to prevent a readmission.
In order for the call center nurses to call patients between 48 and 72 hours after discharge, it is essential the hospitalists send their discharge notes within 48 hours after the patient's discharge. Hospitalists are reminded to send their discharge notes within this time period by physician group leaders at weekly meetings and by IPC, which tracks hospitalists' compliance, according to Irene Kuizon, DO, a hospitalist at Mercy Hospital in Miami. At IPC, the hospitalists' bonus opportunity is connected to the timely sending of their discharge notes.
Inclusiveness
Successful communication is also dependent on the inclusion of all stakeholders. The call center nurses, the hospitalists, primary care physicians and patients are all in contact to coordinate care post-discharge. The call center nurses also contact home health agencies and insurance companies when needed.
"We have to have all the parties taking care of the patient involved," Ms. Ashton says. "The more that we keep the parties updated on the discharge of the patient, the better chance this patient is going to have to [receive appropriate care] after discharge."
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