RARE Action Learning Day, November 2012

Park NicolletPost Hospital Discharge Follow Up Calls

Karen Loscheider, RNKris Kopski, MD, PhD

Project Goals

• Reduce readmissions by better supporting the transition from hospital to home

• Telephone calls made to patients 24-48 hours after discharge from hospital

• Early identification of problems and implementing an action plan

• Ensuring the appropriate follow up appointment has been scheduled

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Project Milestones

• Identified the right patients to be contacted• Defined call questions and appropriate actions for

variances• Built documentation tools in Epic• Trained nursing staff • Connected with the inpatient care teams• Developed Epic monitoring reports

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High Level Outcomes

• Primary Care patients discharged to home are being called

• Surgical and specialty patients will also begin receiving calls using the same process

• Other specialty areas look to mimic this standard process into their existing process

• Utilize the monitoring report to evaluate areas for improvement

• High satisfaction from both patients and staff

Head + Heart, Together

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Challenges

• Complex patient-who should call them? • Creating reporting that best reflect the process• Resources to conduct the calls consistently 24-48 hours

after discharge• System wide implementation

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Process Improvement

• Measure call completion rate• Teach to the call pilot• Establish advanced access into primary care schedules

for hospital follow up appointments• Setting recommended follow up appointment intervals

based on patient readmission risk• Root cause of readmissions at our hospital specifically

will we need to change the questions we are asking?

Head + Heart, Together

Head + Heart, Together