Enhanced Transitions of Care: Centralizing Discharge Phone Calls Improves Ability to Reach Patients and Reduces Hospital Readmissions

Schuller, Kristin; Kash, Bita A.; Gamm, Larry

doi:10.1097/jhq.0000000000000063

Cited by 6 publications

(3 citation statements)

References 26 publications

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“…Components of interventions included pharmacist-led interventions [48], nurse-driven interventions [49], case management [50], post-discharge telephone calls [51], heart-failure-specific follow-up, and early supported discharge for stroke patients [52]. RCTs also examined the use of a virtual ward model to promote inter-professional community care, nurse-led telephone support, nurse-based case management, and a discharge nurse led intervention to promote self-management of care at home.…”

Section: Resultsmentioning

confidence: 99%

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Coffey

Leahy‐Warren

Savage

et al. 2019

IJERPH

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Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

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Section: Resultsmentioning

confidence: 99%

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Coffey

Leahy‐Warren

Savage

et al. 2019

IJERPH

View full text Add to dashboard Cite

show abstract

“…Different types of models have been studied to determine which is most effective at reaching the most patients including nurse-led, pharmacy-led, physician-led, as well as those with decentralized or centralized call centers. [10][11][12][13] For most health systems, reaching every patient is not feasible given the large volume of discharges and significant staff resources that this entails. To address this, post-discharge telephone programs have been implemented that use automated, voice-enabled calls that contact and screen patients to identify recovery needs, and then triage patients for additional telephone follow-up with a clinician.…”

Section: Introductionmentioning

confidence: 99%

“…Post‐discharge telephone call programs seek to reach every patient. Different types of models have been studied to determine which is most effective at reaching the most patients including nurse‐led, pharmacy‐led, physician‐led, as well as those with decentralized or centralized call centers 10–13 . For most health systems, reaching every patient is not feasible given the large volume of discharges and significant staff resources that this entails.…”

Section: Introductionmentioning

confidence: 99%

Automated telephone follow‐up programs after hospital discharge: Do older adults engage with these programs?

Harrison

Sudore

Auerbach

et al. 2022

J American Geriatrics Society

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Background Health systems have developed automated telephone call programs to screen and triage patients' post‐hospital discharge issues and concerns. The aims of our study were to determine whether and how older adults engage with automated post‐hospital discharge telephone programs and to describe the prevalence of patient‐reported post‐discharge issues. Methods We identified all telephone calls made by an urban academic medical center as part of a post‐hospital discharge program between May 1, 2018 and April 30, 2019. The program used automated telephone outreach to patients or their caregivers that included 11 distinct steps 3 days post‐discharge. All adults discharged home from the hospital, were included, and we categorized patients into ≤64 years, 65–84 years, and ≥85 years age groups. We then compared call reach rate, completeness of 11‐step calls and patient‐reported issues between age groups. Results Eighteen thousand and seventy six patients were included. More patients 65–84 years old were reached compared to patients ≤64 years old (84.3% vs. 78.9%, AME 5.52%; 95%CI: 3.58%–7.45%). Completion rates of automated calls for those ≥85 years old were also high. Patients ≥85 years old were more likely to have questions about their follow‐up plans and need assistance scheduling appointments compared to those ≤64 years old (19.0% vs. 11.9%, AME 7.0% (95%CI: 2.7%–11.3%). Conclusion Post‐hospital automated telephone calls are feasible and effective at reaching older adults. Future work should focus on improving discharge communication to ensure older adults are aware of their follow‐up plan and appointments.

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Measuring Team Effectiveness in the Health Care Setting: An Inventory of Survey Tools

Kash

Cheon

Halzack

et al. 2018

Health�Serv�Insights

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Background:Guidance for measuring team effectiveness in dynamic clinical settings is necessary; however, there are no consensus strategies to help health care organizations achieve optimal teamwork. This systematic review aims to identify validated survey instruments of team effectiveness by clinical settings.Methods:PubMed, MEDLINE, and ISI Web of Knowledge were searched for team effectiveness surveys deployed from 1990 to 2016. Validity and reliability were evaluated using 4 psychometric properties: interrater agreement, internal consistency, content validity, and structural integrity. Two conceptual frameworks, the Donabedian model and the Command Team Effectiveness model, assess conceptual dimensions most measured in each health care setting.Results:The 22 articles focused on surgical, primary care, and other health care settings. Few instruments report the required psychometric properties or feature non-self-reported outcomes. The major conceptual dimensions measured in the survey instruments differed across settings. Team cohesion and overall perceived team effectiveness can be found in all the team effectiveness measurement tools regardless of the health care setting. We found that surgical settings have distinctive conditions for measuring team effectiveness relative to primary or ambulatory care.Discussion:Further development of setting-specific team effectiveness measurement tools can help further enhance continuous quality improvements and clinical outcomes in the future.

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Enhanced Transitions of Care: Centralizing Discharge Phone Calls Improves Ability to Reach Patients and Reduces Hospital Readmissions

Abstract: Centralizing the DPC program within a call center helps reach more patients and reduce readmission rates further compared with noncentralized DPCs.

Cited by 6 publications

References 26 publications

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Automated telephone follow‐up programs after hospital discharge: Do older adults engage with these programs?

Measuring Team Effectiveness in the Health Care Setting: An Inventory of Survey Tools

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