Discharge Follow-up Phone Call Program

Not Applicable

Completed

Brief Summary: The goal of this project is to quantify the impact of post-hospital discharge follow-up phone calls on hospital readmission, ED visits, patient satisfaction, and mortality in a general medicine inpatient population. We will obtain exploratory information on patient sub-groups at high risk for hospital readmission and on those experiencing high benefit from the follow-up phone call intervention. In addition, we will obtain data on discharge plan implementation assistance needed to support a successful transition from inpatient to outpatient care among those reached by the intervention phone call.

Detailed Description: RATIONALE

In the current medical literature, it is unclear how follow-up calls influence these outcomes in a general medical population. Some studies have attempted to address this question, but are limited in that they target very specific patient populations, are of insufficient quality, or evaluated follow-up calls as part of a larger care bundle. We will conduct a high quality, real-time clinical care study to determine the efficacy of a follow-up phone call program.

STUDY DESIGN

This is a single center, pragmatic, randomized, controlled clinical trial to investigate whether a structured post-hospital discharge follow-up phone call can improve patients' transition from in-hospital to outpatient care and improve satisfaction with their care. We will also identify the discharge implementation assistance given to those in the intervention (Phone Call) group.

Outcome Measures Primary outcome for this study is readmission event rate within 30 days. Secondary outcomes include patient satisfaction which will be measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores, all cause VUMC emergency department (ED) visits, the need for assistance with discharge plan implementation, and 30 day mortality.

Recruitment & Eligibility

Inclusion Criteria

VUMC patients discharged after an inpatient status hospital stay on a general medicine service.

Exclusion Criteria

Arm && Interventions

Group	Intervention	Description
Phone Call Group (Intervention Arm)	Follow-up Phone Call	Follow-up phone call intervention: Patients will receive the first call attempt within 72 hours of hospital discharge with a maximum of 3 call attempts by the study nurse made up until post-discharge day 7. The semi-structured script embedded within the program specific electronic health record Discharge Phone Call Starform is used to guide a conversation to obtain information on potential causes of hospital readmission that can be identified and addressed to improve each patient's transition to outpatient care.

Primary Outcome Measures

Name	Time	Method
Number of Participants With In-patient Re-admissions	30 days	Number of participants with in-patient re-admissions

Secondary Outcome Measures

Name	Time	Method
Patient Satisfaction: Experience	Within 60 days of Discharge	Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Higher scores indicate more patient satisfaction. Range is 0-9 with 9 being the most satisfied.
Patient Satisfaction: Likelihood to Recommend the Facility (Top Box Rating)	Within 60 days of Discharge	Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Number of patients that reported a score of 3. Range is 0-3 with 3 being highest satisfaction.
Patient Satisfaction: Hospital Experience (Top Box Rating)	Within 60 days of Discharge	Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Number of patients that rated the Hospital Experience as 9. Scale range is 0-9. Higher scores indicate more patient satisfaction.
Patient Satisfaction: Likelihood to Recommend the Facility	Within 60 days of Discharge	Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Scale range is 0-3. Higher scores indicate more patient satisfaction.
VUMC Emergency Department (ED) Visits	30 days	All cause ED visits following discharge
Number of Patient Received Discharge Plan Implementation Assistance	30 days	Need for assistance in implementing discharge plan
Mortality	30 days	All cause mortality