American College of Physicians: Internal Medicine — Doctors for Adults ®

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MDs phone homes

Post-discharge calls smooth transitions

From the February ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Stacey Butterfield

Among all the advanced technologies—monitors, scans and medications—available to hospitalists, one of the best tools for helping recently hospitalized patients thrive may be one of the oldest and simplest: the telephone.

Hospitalist John R. Nelson, FACP, learned this lesson by watching older doctors when he was just starting out in practice. “There was a surgeon who I thought had rather poor bedside manner but in fact patients loved him. He was regarded as a community treasure. One of the things he did was call patients,” said Dr. Nelson, medical director of the hospitalist program at Overlake Hospital in Bellevue, Wash.

MDs phone homes

Whether they’re aiming for community treasure status or just clearing up confusion about medications, hospitalists (and patients) have much to gain from post-discharge phone calls, experts say, including greater patient satisfaction and reduced readmission rates.

The phone calls can also be made by nurses, pharmacists, case managers or even trained call-center workers. Hospitalist programs around the country are employing a variety of methods to complete these transition-smoothing calls, and each system has its own pluses and minuses.

Why call?

The perils of the transition from inpatient to outpatient are well known to hospitalists. “I might send patients home on a medicine never realizing they’re already on one that’s very similar because they never told me. I might send them home stressing the importance of getting their blood checked in a few days and call them only to realize they were feeling OK and decided not to get their blood checked,” said Dr. Nelson.

A quick conversation (Dr. Nelson estimates his average follow-up phone call at three minutes) can alleviate these sorts of problems. “About 10% of the time there’s some clinical medicine that happens during that phone call,” he said.

The other 90% of the time, the call serves as a patient satisfaction tool. “I wanted to do it so patients would like me and I’d be less likely to be sued,” said Dr. Nelson.

Patient satisfaction—along with patient safety—is also a motivation for IPC The Hospitalist Company’s post-discharge phone call program. Although the purposes are similar, the setup is quite different from Dr. Nelson’s solo phone calls: The company’s post-discharge calls come from a national call center.

When an IPC hospitalist writes a discharge summary, the information creates a survey that is conducted over the phone between the non-licensed call-center worker and the patient two days after discharge.

The content, as well as the parties involved, is quite different in these calls. The IPC survey most often elicits the logistical issues that hinder patient compliance—difficulty getting medication covered by insurance, scheduling an appointment with the primary care physician, or obtaining other services or supplies.

“We found that almost 10% of the time when you order home health or durable medical equipment (DME), it never shows up at the house,” said Brian P. Donovan, FACP, regional director for IPC in Tennessee.

If the call-center employee uncovers such a problem, he or she passes it along to a nurse case manager to handle. “If the patient does not have an appointment, we call the primary care office and get the patient an appointment,” explained Isela Sotolongo, IPC executive director for southeast Florida. “A lot of times patients call their primary physician and say, ‘I’d like an appointment.’ They don’t know to say, ‘I just got discharged and I need to see the doctor within 72 hours.’“

Like Dr. Nelson, the call center finds that most patients don’t need anything from their hospitalist service. “In 80% of cases, it verifies that they have what they need, they’re doing well,” said Kathy Loya, vice-president of health services for IPC.

Who should call?

However, for the patients who do need help, the resources brought to a phone call by a hospitalist and a call-center surveyor obviously differ. When a patient raises a clinical issue, Dr. Nelson can usually deal with it immediately. “The patient says ‘I had a question about these two medicines.’ Odds are, the only person who can answer that question on the spot is the doctor,” he said.

If the patient’s issue is more logistical than clinical (insurance, medical equipment, etc.), though, there’s not much a busy hospitalist can do. “I sympathize,” said Dr. Nelson. IPC’s case managers, on the other hand, delve into these kinds of problems. “The nurses could work anywhere between one to three hours per patient on the issues,” said Ms. Loya.

Some of that time may be spent communicating with the patient’s outpatient physician, which is also the procedure when a clinical issue comes up during the call. “Most of the physician contact would actually be with the outpatient providers as opposed to backtracking and talking to the hospitalist,” said Ms. Loya. “Our goal is transition management, to try to get the patient effectively into the hands of the outpatient provider.”

Working toward that same goal, other hospitalist programs have developed systems somewhere in between the lone doctor with a phone and the national call center. In the Geisinger Health System, a transitions-of-care project targets patients at high risk of readmission and assigns them an outpatient nurse case manager, also called a health navigator.

“They make sure the patient gets a call within 72 hours of discharge. That nurse does medication reconciliation, makes sure that the patient has a follow-up with their primary care physician in three to seven days, and helps with any needs the patient may have, whether it be DME or something else,” said John B. Bulger, FACP, director of hospital medicine at Geisinger in Danville, Pa.

Electronic medical records shared between inpatient and outpatient offices facilitate the call by allowing the nurse to see what happened to the patient in the hospital. A system in which follow-up appointments are made before discharge also elim-inates at least one of the potential transition issues.

“We tell them, ‘Your appointment with your family doctor is Tuesday at noon.’ It’s printed on their discharge instructions,” explained Dr. Bulger.

Calling the doctor first

Ensuring that those outpatient visits take place—and include all the necessary information—is the focus of follow-up phone calls made by the hospitalist program at Orange Regional Medical Center in Middletown, N.Y. “Our care really should be continuing until the patient makes that first visit with the primary care physician,” said Diane S. Pine, ACP Member, medical director of the hospitalist service.

Hospitalists in her program notify one of the program’s quality assurance coordinators before a patient is discharged. “They give them two pieces of information: 1) who the patient is going to follow up with and 2) what is the pending information,” said Dr. Pine. “We noticed that when a patient was discharged, there were many loose ends—pending test results or lab results.”

After discharge, the coordinator contacts the designated outpatient physician’s office to make sure that they’ve received whatever results were pending and are scheduled to see the patient. “If the patient does not have a scheduled appointment or has not followed up, the patient is called at home. If the patient still doesn’t see their primary, they send a registered letter,” said Dr. Pine.

The system may not inspire the same enthusiasm as a personal phone call, but it does get a response out of patients. “Sometimes the patients will get letters and get very upset, saying, ‘Please tell the doctor I really appreciate what she did and I’m going to see my doctor, I promise,’“ Dr. Pine described.

Although it’s hard to measure results, she believes the program reduces medical and legal risk. Under the current reimbursement system, none of these follow-up programs provides direct financial benefit to hospitals or hospitalist programs, because their most likely result is a reduction in readmissions.

Rewarding the effort

But hospitalist programs have found motivations—in addition to improved quality of care—to convince their doctors to participate. In Dr. Pine’s program, participation in the follow-up tracking is tied to hospitalist bonuses. At Geisinger, “we try to align the incentives as much as we can. There’s a program that will incent them to play ball with the health navigators,” said Dr. Bulger.

Soon Medicare may add incentives as well, according to Mark V. Williams, FACP, chief of the hospital medicine division at Chicago’s Northwestern Medical Center. “It’s highly likely there will be penalties in the health care legislation for hospitals that have high readmission rates. Efforts that can successfully reduce hospital readmission rates will be financially beneficial to the hospital.” Improvements in patient satisfaction scores are also usually worth something to hospital leaders, he noted.

Dr. Williams is one of the leaders of Project BOOST, a discharge improvement program—ongoing in 30 hospitals and looking to expand further—that, among other initiatives, encourages phone follow-up with discharged patients. “Primarily they’ve centered around having nurses call the patient or a pharmacist or a social worker,” he explained. “At places that I’ve seen implement this, the floor nurses, especially the ones who discharged the patient from the hospital, really enjoy doing this.”

Whoever makes the call, the objective is the same. “There should be some kind of check-in with the patient in probably the 48- to 72-hour time frame to make sure they’ve made that transition from the hospital setting, where basically everything is taken care of, to now, when the patient is responsible for their own care,” said Dr. Williams.

A step beyond

What if that check-in were in person, instead of over the phone? That’s the idea behind a new program that Kirk Mathews, CEO and co-founder of Inpatient Management Inc. of St. Louis, is trying to launch in some of the hospitals his company serves.

“We are in some markets where the primary care shortage is so great that the first follow-up visit from a patient, particularly an unassigned patient, might not be for a month or more after discharge,” Mr. Mathews said. His solution is to open a part-time clinic within the hospital, staffed by a mid-level provider and supervised by a hospitalist, where patients could come for their first post-discharge visit.

The project is currently in the discussion stages; it still has to clear the concerns of outpatient and inpatient physicians. “A lot of hospitalists would look at it as practice creep,” noted Mr. Mathews. There’s also the challenge of inpatient clinicians learning how to bill for outpatient care.

But if the idea gains physician and administration support, patients who are at high risk for readmission could start being seen in these hospitalist follow-up clinics as soon as the first quarter of 2010, Mr. Mathews said.

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Make your own follow-up phone call

John R. Nelson, FACP, calls most of the patients that he discharges from the hospital. He offered some advice on getting the most out of this final clinical encounter.

Don’t be afraid. “Many hospitalists just fear that they will take 15 minutes each and it will take all day to make the phone calls,” said Dr. Nelson. “I bet my average call is three minutes.”

Surprise them. “I never tell patients in advance that I’m going to call, because some of them I forget, or for whatever reason a call to them falls through the cracks. If I don’t call, they’re going to be really unhappy. And when I tell them to expect it, then when I do call, they’re much less impressed.”

Do it in the downtime. “I call only when it suits me. If I’m busy today, I’m not going to call any patients.”

It’s not phone tag. “I leave a message on the answering machine and say, ‘I was just thinking about you. I hope things are going well. Be sure to take that blood pressure medication like we talked about. See your doctor next week and you don’t need to call me back but if you have anything you want to let me know, here’s the number.’“

Talk to the right person. If the patient has dementia or another condition that causes them not to be caring for themselves, call the caregiver instead. “I call the daughter or son who is the one looking after their elderly parent.”

Finally, prepare for appreciation. “Typically patients will say, ‘Geez, I’ve never had a doctor call me before. If I have to be in the hospital again, can you be my doctor?’ Sometimes they’re the same patients who I think weren’t too happy with me when they left the hospital,” said Dr. Nelson.

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