Post Discharge Calling

By Mary Jo Gorman, M.D.

Apr/May 2006

Hospital care doesn't need to end upon discharge.  Nor should it.  That is why there is a growing recognition that it is incumbent upon the hospital and/or attending physician to make sure that a patient's transition from inpatient to home is not only as smooth as possible from a comfort standpoint, but is as medically sound, comprehensive, and understandable as can be.

One of the best ways to achieve this is through the establishment of a professionally staffed call center that contacts patients shortly after discharge to check on their clinical stability, assure a successful transition to home, and intervene with information or action when needed.  These are more than simple customer service calls, although ascertaining patient satisfaction should be part of the call and can provide valuable information that improves the hospital experience.  These are calls that demonstrate that discharging a patient doesn't mean discharging responsibility.

More and more, evidence is showing that follow-up, clinically oriented calls are vitally important to the physical health and ongoing well-being of the patient and should therefore be considered an essential part in the provision of care.  We know.  We see it every day. 

IPC is a hospitalist company, employing more than 300 physicians who collectively have more than 1.2 million patient encounters annually.  Included in that is a call center staffed by four nurses (with case management and critical care backgrounds) and eight patient representatives, all of whom have medical backgrounds.  This call center team contacts all patients within 48 to 72 hours of discharge.  The patients we have been able to help through these calls strongly suggest that other healthcare organizations - from hospitals to medical groups - would be well advised to similarly establish their own transition-management program with a call center at its apex.

In fact, the Society of Hospital Medicine (SHM),  the professional organization representing hospitalists nationwide, has acknowledged that the period immediately following hospital discharge and prior to initial follow up with an ambulatory provider is an important transition that requires "detailed attention to ensure optimal outcomes."  As a result, this past May, SHM passed a resolution supporting the development of systems that provide for just such a transition management program.

The information gathered through post discharge calls can serve as a catalyst for systemic changes in how care is delivered and communicated.  For example, nearly one out of eight patients discharged from a hospital report new or worse symptoms within two to three days after going home.  Yet despite feeling worse, these patients are only minimally more likely to make follow-up appointments to address their new healthcare concerns.  Clearly, there is great room for improvement.

It was also found that nearly four in ten discharged patients (38.4%) had one or more issues post-discharge.  In addition to worsening symptoms, 10% of the patients contacted had medication issues varying by age, insurance plan, and health status (for example, patients under the age of 60 were less likely to fill their prescriptions while those over 60 were less likely to understand how to take their medications).  Other issues encountered daily, include inadequate coordination with home health services and failure to schedule a follow-up appointment in the desired time. 

The reasons for such issues arising are many.  Therefore, part of the purpose for the post discharge call is to gather the data needed to understand deficiencies in the system so that important changes can be made.  Sometimes patients simply procrastinate upon going home - not fully appreciating the urgency of their follow-up direction.  Other times, the cost of follow-up care may be a roadblock.  For example, an insurance plan may or may not cover certain types of follow-up home care, or an HMO may only approve specific medications and what is covered at the hospital may not be covered as an outpatient.  The job of the call center is to help the patient navigate through these challenges and arrive at a successful and affordable conclusion. 

Many times the greatest issue consumers face is simply one of confusion.  Medical care has become so complex that patients often go home from the hospital with, what has been described  as a "loss of direction" about what to do, where to go, and whose advice to follow.  Follow-up calls from a knowledgeable representative can help provide just such direction.  They are very much appreciated by consumers not routinely accustomed to such personalized care and attention upon returning home.

The stories learned from patients when they have been contacted and the positive impact we've had on their health is living evidence of the value of such calls.  One elderly heart patient, for example, was discharged on Coumadin but was already taking Warfarin, which is the same drug.  Upon calling we found out that this patient was confused, didn't see the overlap and as a result, was dangerously taking both.  The call center staff was able to straighten that out immediately.  Another patient went home from the hospital after having an angiogram was experiencing a little bleeding seeping out of the groin area.  The call center contacted the cardiologist immediately to inform him of the patient's condition and to obtain further instructions for the patient.  Intervention was both clinically necessary and psychologically comforting for the patient.

In addition, such calls can have a quantifiable impact on care itself.  Statistics from 2004 show readmit rates for hospitalized patients were a significant 44 percent below national industry standards.  Tracking nearly 30,000 patients in eight DRG (Diagnostic Related Groups) categories within 31 days of discharge resulted in a readmit rate of 2.6% versus the 4.6% national benchmark established by the Maryland Hospital Association Quality Improvement Project.  These results are, in part, due to a strong commitment to transition planning and management.

Couple the data these calls have unearthed with smaller, similar studies previously conducted, and one would think that follow-up calls by hospitals or medical groups would have by now become the norm.  Unfortunately that is simply not the case.  Many HMOs do contact members upon discharge, but usually only those members who have been flagged in the health plan's system because of certain recurring medical conditions (kidney, liver, etc.).  So too, many same-day surgery centers make follow-up calls and some specific procedures at hospitals may automatically trigger this kind of follow-up attention.  Still, such episodic programs are far from establishing the consistent, transition-management processes needed to reduce both the patient's confusion as well as the rate of incomplete services post-discharge. 

Much effort and good discharge planning takes place daily at hospitals around the country.  The final step in this is the consistent tracking of the problems patients identify post-discharge.  Doing so will allow a hospital or medical group to re-examine its processes and work towards lessening the number of discharged patients who experience critical obstacles or information gaps.

Mary Jo Gorman, M.D., MBA, is chief medical officer of IPC-The Hospitalist Company and president-elect of the Society of Hospital Medicine.