Creating a reliable system for outreaching with patients in transition

Purpose:
We are a multisite health care organization. We identified the need to improve the quality of patient care when they are discharged to home from the emergency room or hospital. We created reports in the EMR and nurses outreach patients utilizing a standard assessment.

Relevance/Significance:
Discharge calls provide the opportunity to prevent adverse events, improve quality of care and increase patient satisfaction. We have a process for reviewing patients who have used either service the primary care nurse reaches out to patients and their families to assess their status. Nurses provide leadership in discharge assessment and work with others to develop strategies for meeting the patient's needs.

Strategy and Implementation:
The day after the patient is discharged from the emergency room or hospital, they populate a report. Staff is responsible for calling patients who were discharged from a medical-surgical unit and whose discharge destination is home. The staff utilizes a standardized survey that includes reviewing the discharge plan and medications. Patients and family need to care for themselves with regard to management of their medication(s), physical care and life style adjustments such as diet and exercise. Motivation of patients and what they perceive as necessary for discharge are likely to be different based on the phase in the chronic illness trajectory and the patient and family experience. We include office visits in primary care with any member of the care team, or the telephone call when the questionnaire is completed. We count all patients who have had a successful discharge review within 2 days of discharge from the hospital and 7 days of discharge from the emergency room.

Evaluation:
We have improved the rate of contacting patients post discharge to 70% of patients are reached within two days of discharge. We have reach 60% of our high risk patients who were discharged from the emergency room. We were able to demonstrate a 20% reduction in both the 72 hour and the 30 day emergency room readmission rate since initiating phone calls post emergency room use.

Implications for Practice:
Building the report in the electronic medical record allows for standardization of our outreach and completion rate. We will continue to track the completion of the contact and the reduction of readmission rates to the emergency room and/or hospital.