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Taking charge after discharge

Post-discharge call services aim to smooth transitions

From the January ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Stacey Butterfield

Someone needs to make the call—that is, the phone call that clarifies instructions and medications for recently discharged patients. But who has the time? At some hospitals, hospitalists or nurses make post-discharge phone calls, but a heavy patient load can make this difficult to fit into the schedule.

In response to this situation, several companies have recently launched post-discharge services, which contract with hospitals to handle the necessary phone calls.

Photo by Thinkstock.

Photo by Thinkstock.



“There was a large need for supporting hospitals as they manage their patients from discharge through to home…They are facing competing and changing priorities, on top of a lack of resources. Not to mention there's the physical challenge of trying to manage patient engagement once they leave the four walls of the hospital,” said Sean Hughes, vice president of Vree Health, a Merck subsidiary that recently launched a post-discharge service called TransitionAdvantage.

The advent of payment penalties for certain readmissions of Medicare patients has been a major motivator for the expansion of the industry, since post-discharge services are thought (if not yet proven) to reduce the risk of readmission. In addition to these potential clinical benefits, some of the services monitor, and aim to improve, patient satisfaction as well.

The services employ a variety of methods and staff. Typically, the post-discharge callers don't have any contact with hospitalists, but they do share a goal. “What we're all trying to achieve is satisfaction and safety,” said Jeff Forbes, president of SironaHealth, which offers a post-discharge service.

Targeted action

Of course, many patients can safely and satisfactorily leave the hospital without the need for extensive follow-up. The post-discharge services focus on those who can't. “Most hospitals are interested in talking with us about the chronic diseases with high readmission rates that Medicare is targeting,” said Joel Wright, vice president of health systems operations for Walgreens, which recently launched a post-discharge service, WellTransitions. “Heart failure is almost always the first one.”

Acute myocardial infarction and pneumonia round out the payment-penalized trio targeted by most services, but post-discharge programs are starting to look at other diagnoses as well, experts said, including chronic obstructive pulmonary disease, asthma and diabetes.

All of the services cover the issues that have been found to commonly arise in these patients. “If there's a follow-up regimen, are there any barriers to compliance with that regimen? [The service's] job is to help remove some of those barriers,” said Mr. Forbes. Potential barriers include problems filling or understanding new prescription regimens.

That's a particular target of the WellTransitions program, which is staffed by pharmacists. The program begins with bedside delivery of outpatient medications right before the patient is discharged and continues with phone calls two, seven and 28 days after discharge.

The pharmacist also conducts medication reconciliation, comparing the patient's outpatient prescription records with the drugs they were prescribed in the hospital. “In the community pharmacy world, we don't ever get discontinuation orders. If a patient stops taking a medication, we rarely get notified. This gives us an opportunity to go through and clean up those prescriptions,” said Mr. Wright.

Transfer of information from the inpatient to outpatient setting is another component of some post-discharge services. Although it depends on the accessibility of a hospital's system, the post-discharge services are generally able to pull at least some information from the inpatient electronic medical record.

“We can take that summary and ensure that the primary care physician, first, actually knows that the patient was in the hospital, and second, receives the information on the discharge,” said Mr. Forbes.

No matter what the state of the medical records, all of the services strive to ensure that the patient has a follow-up outpatient appointment.

“A lot of the patients don't know where to go. ‘The discharge instructions you gave me were handwritten and I didn't know what that said. I don't know who to call because I can't remember the name of the nurse. I don't remember which doctor because I saw eight during my stay,’” described Nicole Nicoloff, vice president of market strategy and innovation at BerylHealth, which offers a post-discharge service.

If a patient reports not having a follow-up, the post- discharge services take action, the specifics of which depend on the service and/or the protocols set by the hospital. They may refer the patient back to the discharge coordinator at the hospital, or take care of the issue immediately.

“The advocate will say, ‘Let's call them right now and make that appointment.’ They'll transfer them into the office and stay on the phone and make sure they do make that follow-up appointment,” said Mr. Forbes.

A check on the patient's current health status is also a component of all the programs, and again, one that varies in its setup. In TransitionAdvantage, for example, the check is conducted daily by a call-center worker trained in motivational interviewing and teachback who goes through pre-set questions based on the patient's diagnosis.

“For example, in congestive heart failure, if the weight fluctuated by more than three pounds in a 24-hour period, that may be an alert that medications may require adjustment,” said Mr. Hughes. After verification that the weight measurement is valid, the caller would take action, triaging the patient up to the program's nurse hotline, or contacting a prespecified in- or outpatient clinician.

In some programs, chronic disease patients get their checkup phone calls directly from a nurse, who either deals with any clinical issues or passes the patient along to someone at the hospital. “The hospital specifies what we're going to follow up on, and specifically how they need that documented,” said Ms. Nicoloff.

The hospital also typically lends its name to the post-discharge service, so that patients see the follow-up as coming from a familiar institution, if not a provider they've met before. (The services' status as a representative of the hospital also allows them to receive patient information without violating privacy regulations.) “It really provides [the hospital] the opportunity to maintain that patient engagement,” Mr. Forbes said.

Seeking satisfaction

The specified issues tackled in the call could include non-clinical ones as well. “For example, was the bathroom clean? Is there any staff that you'd like to recognize?” said Mr. Forbes. Most of the post-discharge services collect satisfaction data at some point in their contact with the discharged patients, then relay the data to the hospital, either as a routine report or more urgently, if necessary.

“If the patient says, ‘I want to sue the hospital,’ the system automatically sends an e-mail to risk management with all the details. If the patient reported that the nurse did a fantastic job, that information is fed back to the unit,” Mr. Forbes said.

The satisfaction component is one of the motivations for hospitals to outsource these phone calls, the experts said. “People are conflict-avoidant. You're not going to tell the nurse who just treated you, ‘You did a crappy job.’ You might be back in there in two months and facing that person,” Mr. Forbes said.

The time pressures on inpatient clinicians were another selling point commonly cited by the post-discharge services. “On the days that you've got a full house, you're expecting these nurses to not only check vitals [and] see more patients than usual, then…make a phone call,” said Ms. Nicoloff. “[Nurses] can't do so many tasks.”

In-house follow-up phone calls may also be an inefficient division of expert labor, added Mr. Hughes. “When we talk with hospitalists and nurses and case managers, they convey that having someone else focused on making phone calls and providing additional support allows them to redirect their valuable resources to patient care,” he said.

There's also the challenge of collecting and acting on the phone call data, which call centers may be better suited to than hospitals. “I can document it, but that doesn't mean I can trend it over time,” said Ms. Nicoloff. “We're able to do data analytics.”

Setting up an in-house follow-up system can also be time-consuming and expensive, the experts noted. Washington Adventist Hospital in Maryland was one of the pilot sites for WellTransitions. “The reason we went with WellTransitions is it was available right away,” said Shahid Shamim, MD, director of the hospitalist program. “If you start initiatives in the hospital…it requires additional staffing.”

The hospital hopes to eventually expand its own post-discharge offerings, but currently, an outside service is the best fit, according to Judy Kurtis, director of case management at Washington Adventist. “For now, we're trying to work with the resources that are available. In today's health care reform and challenges, you have to spend money to save money, and you have to look at these kinds of programs to keep people well,” she said.

The money spent on hiring someone to do your post- discharge phone calls is the primary downside of the systems. The post-discharge services typically contract with hospitals on a set fee-per-patient basis, but in the future, other models might be explored.

“There are definitely discussions that we are having around the accountable care model,” said Mr. Wright. “We would help avoid penalties and share in the savings.”

Mr. Forbes had additional ideas on how accountable care could change the payment structure. “I think you're going to be able to get [funds from throughout] the entire supply chain, from DME [durable medical equipment] organizations to visiting nurse organizations.…I expect employer groups to pay,” he said.

Before they agree to kick in for the phone calls, those groups are likely to want evidence that post-discharge services improve outcomes or reduce costs. “There's no significant outcomes research or controlled clinical trials to support a lot of the practices, so we are engaged currently in creating more evidence,” said Mr. Hughes. TransitionAdvantage piloted in an outcomes trial at a few hospitals last year and fully launched just this month.

WellTransitions is also newly launched and collecting data. At Washington Adventist, 48 high-risk patients participated in the pilot and only three were readmitted within 30 days.

Spence Hudon is clinical manager of the inpatient heart failure units at Sarasota Memorial Hospital, one of the other pilot sites. “I do feel like it's making a difference in our patients' lives,” he said. “And if it prevents one admission, we've probably paid for hundreds of patients.”

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